Balance Problems and Vertigo

Balance depends on signals that reach the brain from three places at once: the inner ear, the eyes, and the sensors in the muscles and joints of the legs and feet. The part of the inner ear that handles balance is called the vestibular system. Its fluid-filled canals register when the head turns, and two small organs beside them sense the position of the head relative to gravity.

When one of these signals is wrong or missing, the brain receives conflicting information. The result can be vertigo, unsteadiness, or a feeling of floating.

People describe balance problems in different ways. Many patients call it “dizziness,” a word that can mean anything from a brief light-headed moment to a long episode of spinning. Symptoms can include:

• A spinning sensation (vertigo)
• Feeling unsteady, staggering when walking, or feeling about to fall
• Light-headedness or a floating sensation
• Blurred vision
• Confusion or disorientation
• Nausea

Symptoms may come and go within minutes or last for long periods. Some people also feel tired or anxious because of them.

There are more than a dozen types of balance disorders, and some begin suddenly with no obvious cause. Among the most common:

• Benign paroxysmal positional vertigo (BPPV). Brief, intense spinning when the head changes position, such as rolling over in bed or looking up. It occurs when small calcium crystals in the inner ear move into one of its canals. BPPV can follow a head injury or develop with age.
• Labyrinthitis and vestibular neuronitis. Inflammation of the inner ear or of the balance nerve, often linked to a viral infection.
• Ménière’s disease. Episodes of vertigo together with hearing loss, ringing in the ear, and a feeling of fullness in the ear.
• Perilymph fistula. A leak of inner-ear fluid, which can follow a head injury, a sudden change in air pressure, or ear surgery.
• Other causes. Medications, ear infections, low blood pressure, and conditions affecting vision or the nervous system.

Balance problems after a head injury are covered in more detail on Traumatic Brain Injury and Balance Disorders.

See a physician if you feel unsteady, if the room seems to spin even briefly, if you feel as if you are moving while sitting or standing still, if you have fallen or feel you are about to fall, or if balance symptoms come with changes in your hearing.

Call 911 if loss of balance comes on suddenly together with weakness or numbness on one side of the body, trouble speaking or seeing, confusion, or a sudden severe headache. These can be signs of a stroke.

The evaluation starts with a detailed history: what the symptoms feel like, what triggers them, how long they last, whether you have fallen, and which medications you take. This is followed by an examination of the ears, the eye movements, and balance.

Depending on the findings, testing may include a hearing evaluation and videonystagmography (VNG), which records eye movements to assess how the inner ear’s balance system is working. Other tests or imaging may be ordered when needed.

It helps to come prepared with:

• A description of your symptoms in your own words
• When they happen, what seems to bring them on, and how long they last
• Any falls, and the circumstances
• A list of all medications, including over-the-counter medicines and supplements

Treatment depends on the cause. It may include repositioning maneuvers for BPPV, medication, treatment of an underlying condition, or vestibular rehabilitation: exercises that help the brain adapt to changes in the balance system. See Vestibular Rehabilitation Therapy and Vestibular Compensation and Rehabilitation.