Dizziness that isn't vertigo

Dizzy is one of the least specific words in medicine. When five people use it in a week, they usually mean five different things, and sorting out which one you mean is genuinely most of the work. So it is worth laying out the categories, because if you can describe yours accurately you have already helped enormously.

The first is true vertigo — a sense that you or the room are actually rotating. That is a false movement signal, and it points fairly firmly at the inner ear or its connections. The second is lightheadedness, a woozy about-to-faint feeling, often when standing up quickly, which is more often about blood pressure, hydration, medication or cardiac issues than about the vestibular system. The third is imbalance or unsteadiness, a sense of being unreliable on your feet without any spinning at all, which can come from the inner ear but also from sensation in the feet, from vision, from strength or from the neck. And the fourth, which people almost never think to mention unless asked, is a visual symptom: the world seems to bounce, blur or lag behind when you turn your head, and reading a sign while walking becomes impossible.

That fourth one can often indicate reduced vestibular function, and it is worth explaining why. You have a reflex — the vestibulo-ocular reflex — whose only job is to move your eyes exactly opposite to your head, at the same speed, so that an image stays fixed on your retina while your head is moving. It is astonishingly fast, far faster than anything driven by vision alone. When one inner ear is under-responding, that reflex loses accuracy, and images slip on the retina during head movement. The result is a world that seems to bounce or smear, called oscillopsia, plus fatigue, visual strain and a general sense of not being able to trust what you are looking at.

People with this rarely have dramatic spinning. What they have is a constant low-grade fog, trouble in busy visual environments, exhaustion by mid-afternoon, and a habit of moving their head as little as possible. That last part is important, because holding your head still feels better in the moment and is precisely what prevents recovery.

The treatment for reduced vestibular function is not a manoeuvre — there are no crystals to move here. It is retraining, and it works because the brain can recalibrate the reflex if you give it the right error signal. The core exercise is gaze stabilization: you fix your eyes on a target and move your head while keeping the target clear. It sounds trivially easy and it is not. Done at the right speed, it produces exactly the mismatch the brain needs in order to adjust its gain. We progress it by changing the speed, the size of the target, the background behind it, whether you are sitting or standing, and eventually whether you are walking.

Alongside that we use habituation work for the movements that provoke you most, and balance retraining that gradually takes away the visual and surface cues you have been leaning on. Here is the part I always tell people at the first visit, because otherwise it is alarming: these exercises are supposed to make you feel mildly symptomatic. Not awful, not for hours afterwards, but a definite two or three out of ten during. Exercises comfortable enough to feel like nothing are not creating the error signal, and they will not drive change.

The timeline can vary from weeks to months or longer and progress is not usually smooth. Good days and bad days are normal, and the pattern that matters is the trend across weeks rather than the reading on any given morning.

If any of that description sounds like what you have been trying and failing to explain to people, it is worth a proper vestibular assessment rather than another round of being told everything looks fine.

Hopefully you found this information helpful. Feel free to contact us for more information or questions! If there are topics you would like to see us cover, definitely drop us an email and it may be featured during a future blog post.

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