Balance and Vestibular Disorders

A spinning sensation triggered by turning in bed, lying down or looking up, lasting under a minute, points to benign paroxysmal positional vertigo 3. Lightheadedness on standing points to blood pressure. Constant unsteadiness without spinning points to sensory loss, weakness or a central cause.

Getting this description right is more diagnostically useful than any scan, and it is the part most often glossed over.

It is caused by displaced crystals in the inner ear canals, diagnosed with a positional test at the bedside, and treated with a repositioning manoeuvre. In randomised trials, symptoms resolved completely in 56% of people after the Epley repositioning manoeuvre, compared with 21% after a sham manoeuvre or control treatment 3.

It is common, it is frequently misdiagnosed as a general balance problem, and people live with it for years unnecessarily. If your dizziness is triggered by head position, ask specifically about this.

After vestibular neuritis and in unilateral vestibular loss, a graded programme of gaze stabilisation, habituation and balance retraining produces substantial improvement 1. It is also used in persistent postural-perceptual dizziness, but there the trials are too few to show whether it works 4.

It works by driving central compensation, which requires provoking the symptom in a controlled way. Avoiding the movements that cause dizziness prevents compensation and is the most common reason people do not recover.

Sudden severe imbalance with double vision, slurred speech, facial weakness, severe headache or numbness can indicate a stroke affecting the balance centers. New unilateral hearing loss with dizziness also needs prompt assessment.

Dizziness alone in an otherwise well person is rarely a stroke, but the accompanying signs are what matter and they are worth knowing.

Benign positional vertigo is corrected quickly by a repositioning manoeuvre. Vestibular loss needs weeks of exercises that provoke symptoms deliberately so the brain adapts. Central causes need investigation rather than exercise.

These are three entirely different treatments, which is why the history matters so much. Its most reliable parts are timing and triggers: in one emergency department study, 52% of patients chose a different word for the type of their dizziness when asked again about six minutes later, while their accounts of duration and triggers stayed consistent 2.

Vestibular rehabilitation works by provoking symptoms at a tolerable level so the nervous system recalibrates. Exercises that produce no symptoms produce no adaptation.

People frequently stop because they assume feeling worse means harm. That expectation is set at the start, along with what level of symptom is acceptable and what is too much.

Moderate to strong where one inner ear has lost function. A Cochrane review of 39 studies with 2,441 people found moderate to strong evidence that vestibular rehabilitation is safe and effective for this group, and moderate evidence that it resolves symptoms and improves function in the medium term 5.

For benign positional vertigo, repositioning manoeuvres worked better than exercise-based rehabilitation in the short term, although combining the two helped longer-term recovery of function 5. The guideline evidence applies to peripheral vestibular loss confirmed on testing; it may not apply to central causes or to dizziness without a diagnosed vestibular deficit 1.