Balance Disorders vs. Vertigo

By Dr. Prateek Porwal, ENT Surgeon & Vertigo Specialist | PRIME ENT CENTER, Hardoi UP
Last Updated: February 2026 | VAI Budapest 2025 Award Recipient

One of the most common confusions I encounter is patients using the words “vertigo,” “dizziness,” and “balance problems” interchangeably. They’re not the same. This distinction matters profoundly because diagnosis and treatment differ based on which one you actually have. A patient with true vertigo needs different management than one with disequilibrium or presyncope. Understanding the difference between these conditions is the first step toward proper treatment.

Defining Terms: Vertigo vs. Balance Disorders vs. Dizziness

Vertigo: The illusion of motion—either that the room is spinning around you, or that you are spinning in space. It’s a specific sensation, not vague. Rotatory, typically with nausea, often with nystagmus (eye jerking). Usually associated with inner ear (peripheral) or brainstem (central) dysfunction.

Dizziness: Umbrella term for multiple different sensations—vertigo, lightheadedness, unsteadiness, confusion. When patients say “I’m dizzy,” it could mean any of several things. We must clarify which.

Balance disorder (disequilibrium): The sensation of being unsteady without the spinning sensation. The person feels like they might fall, especially with eyes closed or in dim light. No room spinning. No lightheadedness. Just poor balance.

Presyncope: The feeling that you’re about to faint. Lightheaded, vision grays out, might feel weak or sweaty. But you don’t actually lose consciousness. Different from vertigo.

Oscillopsia: The sensation that the visual world is bouncing or jiggling when moving. The person sees blurred movement when they move their head. Associated with vestibular dysfunction.

Common Balance Disorders and Their Characteristics

Bilateral Vestibular Hypofunction (BVH)

Both vestibular systems are compromised, either acutely (from infections affecting both ears or ototoxic medications) or chronically (age-related degeneration, recurring infections).

Presentation: Chronic unsteadiness, especially in dim light or with eyes closed. May have oscillopsia when moving head quickly. No acute spinning episodes—rather chronic imbalance. Gets worse in darkness (can’t rely on vision for balance). Difficulty with stairs or uneven surfaces.

Diagnosis: VNG testing shows reduced responses bilaterally. Head impulse test shows inability to maintain gaze during head movements. Balance tests show poor performance.

Management: VRT emphasizing proprioceptive and visual compensation. Walking stick for safety. Ensure adequate lighting. No medication helps; rehabilitation is primary treatment.

Cerebellar Ataxia

The cerebellum coordinates movement and balance. Cerebellar damage (from stroke, tumor, atrophy, or hereditary conditions) causes unsteady gait and incoordination.

Presentation: Wide-based unsteady gait (looks like drunken walk even sober), difficulty with fine movements, dysarthria (speech difficulty), sometimes nystagmus. No spinning sensation. Often accompanied by other neurological signs (weakness, numbness, cognitive issues if cerebellar stroke large).

Diagnosis: MRI shows cerebellar pathology. Neurological exam shows specific cerebellar signs. Not a vestibular problem despite balance dysfunction.

Management: Depends on underlying cause. Stroke management, tumor treatment, or rehabilitation for hereditary ataxias. Physical therapy helps maximize remaining function.

Parkinson’s Disease and Parkinsonian Syndromes

Progressive neurological disease affecting motor control. Balance problems develop as disease progresses.

Presentation: Early: resting tremor, rigidity, slowness. Balance problems appear later as postural instability develops. Patient loses ability to correct when stumbling. Freezing (sudden difficulty walking despite wanting to). Orthostatic hypotension (dizzy on standing) from autonomic dysfunction.

Not vertigo: No spinning sensation. Patient knows they can’t balance but has no illusory sense of motion.

Management: Medication (dopamine agonists), physical therapy for balance, occupational therapy for adaptation. Neurologist typically manages.

Cervical Vertigo and Cervical Dysfunction

Cervical vertigo is controversial but refers to dizziness or balance problems associated with neck problems (arthritis, whiplash, muscle tension).

Proposed mechanism: Cervical proprioceptive receptors help with balance. Neck dysfunction disrupts proprioceptive input. However, this remains debated among specialists.

Reality in practice: I see patients told they have “cervical vertigo” when they actually have BPPV or other inner ear problem that coincidentally improves with neck treatment (because any treatment helps if you wait long enough). But genuine cervical contribution exists in some cases.

True cervical dysfunction: Balance problems associated with clear neck pathology on imaging and examination, improves with neck-specific treatment, no evidence of inner ear or central cause.

Persistent Postural Perceptual Dizziness (PPPD)

PPPD is increasingly recognized as a distinct condition. Patient has chronic dizziness and balance problems (not true vertigo spinning, but chronic unsteadiness) triggered by vestibular events but persisting after the initial event resolves.

Example: Patient has vestibular neuritis, which resolves. But despite normal vestibular function, they continue feeling unsteady and dizzy for months or years. Brain has essentially become “sensitized” to balance threats.

Triggers for PPPD:

• Any vestibular event (BPPV, vestibular neuritis, labyrinthitis)
• Anxiety disorder preceding or following vestibular event
• Motion sensitivity (visually triggered dizziness)
• Height sensitivity
• Fear of falling

Characteristics: Chronic symptoms (weeks to months to years), sensitivity to motion or height, anxiety about symptoms, may appear “out of proportion” to objective findings (balance tests normal but patient very symptomatic). Worsens with stress.

Treatment: Cognitive behavioral therapy, graded vestibular rehabilitation, SSRIs sometimes helpful. Not a structural problem—brain needs retraining.

Anxiety-Related Dizziness

Anxiety and panic disorder can cause dizziness and balance symptoms despite normal vestibular and neurological function.

Presentation: Dizziness during or before panic attacks, lightheadedness, feeling faint, balance unsteadiness, often accompanied by chest tightness, shortness of breath, sweating. Symptoms typically episodic related to anxiety triggers.

Distinguishing from vestibular: No true vertigo (spinning sensation). Symptoms associated with anxiety symptoms (chest tightness, fear, catastrophic thinking). Often worse with anticipatory anxiety (fear of dizziness causes dizziness—vicious cycle).

Management: Treat underlying anxiety disorder (SSRI medications, cognitive-behavioral therapy, mindfulness). Once anxiety controlled, dizziness usually resolves.

Orthostatic Hypotension

Blood pressure drops excessively on standing, causing presyncope—lightheadedness, graying vision, weakness. Patient feels faint but doesn’t usually actually faint (though can if severe).

Causes: Medications (blood pressure meds, diuretics, antidepressants), dehydration, prolonged bed rest, autonomic dysfunction, anemia.

Not vertigo: No spinning sensation. No nausea. Resolves quickly when lying down.

Management: Address underlying cause, increase salt and fluid intake, compression stockings, medications if necessary. Change position slowly.

Assessment Tools for Balance Disorders

Clinical Balance Tests

Romberg test: Stand with feet together, eyes closed. Normal people maintain balance; those with proprioceptive loss or vestibular dysfunction sway or fall

Single leg stance: Stand on one leg, eyes open and closed. Balance difficulty indicates vestibular or proprioceptive dysfunction

Tandem gait: Walk heel-to-toe in straight line. Difficulty indicates balance dysfunction

Coordination tests: Finger-to-nose test, rapid alternating movements—assess cerebellar function

Gait observation: Watch how patient walks. Provides diagnostic clues (parkinsonian gait, cerebellar gait, fearful gait)

Berg Balance Scale (BBS)

Quantified test of 14 balance tasks. Scores 0-56. Lower scores indicate higher fall risk. Standard assessment tool in rehabilitation.

Tinetti Balance and Gait Assessment

Tests balance (sitting, standing, standing with eyes closed, standing on one leg, reaching, turning, standing on one leg with other leg extended) and gait (initiation, step length, step height, step symmetry, step continuity, path, trunk sway, walking stance). Quantifies fall risk.

Computerized Dynamic Posturography (CDP)

Advanced testing where patient stands in booth with moving walls/floor. System objectively measures balance responses to different sensory challenges. Can identify which balance system is dysfunctional (vestibular, proprioceptive, or visual). Expensive but definitive for complex cases.

Video Nystagmography (VNG)

Infrared cameras track eye movements. Records nystagmus patterns during Dix-Hallpike maneuver or head movements. Objective assessment of vestibular function. Standard vestibular testing.

Management Differences: Vertigo vs. Balance Disorders

Condition	Primary Treatment	Medication Role	Rehabilitation Role
BPPV	Repositioning maneuver (definitive)	Anti-nausea only	Rarely needed if maneuver works
Vestibular Neuritis	VRT exercises (essential)	Anti-nausea acutely; vestibular suppressants briefly	Primary long-term treatment
Bilateral Vestibular Loss	VRT emphasizing substitution	Minimal role	Essential; focuses on vision and proprioception
Cerebellar Dysfunction	Physical/occupational therapy	Minimal; depends on cause	Essential for adaptation
Parkinson’s	Dopaminergic medications	Medication primary	Supportive; PT for mobility
PPPD	Cognitive-behavioral therapy	SSRI sometimes helpful	Graded VRT; psychological retraining
Anxiety-Related	Treat anxiety disorder	SSRI, anti-anxiety drugs	Cognitive-behavioral therapy primary
Orthostatic Hypotension	Address root cause	Salt, fluids, possibly fludrocortisone	Positional training

India-Specific Challenges in Balance Disorder Diagnosis

Misdiagnosis as vertigo when it’s actually balance disorder: Many Indian patients diagnosed with “vertigo” don’t actually have true spinning sensation. Proper questioning reveals they’re unsteady, not spinning. Affects treatment.

Vitamin D deficiency: Prevalent in India, contributes to both vestibular dysfunction and muscle weakness. Often missed as contributing factor to balance problems. Supplementation helps.

Arthritis and cervical dysfunction: Common in elderly, sometimes blamed for dizziness when true cause is vestibular or neurological. Requires careful differentiation.

Anxiety-related symptoms: Common in India but often attributed to supernatural causes or misdiagnosed as serious disease. Proper psychiatric assessment important.

Limited diagnostic equipment: Not all areas have access to VNG, CDP, or advanced imaging. Clinical assessment and history become even more important.

Frequently Asked Questions About Balance Disorders

Is my problem vertigo or a balance disorder?

Key question: Do you have the sensation that the room is spinning, or that you are spinning? If yes, it’s likely true vertigo (inner ear or brainstem problem). If your sensation is just being unsteady without spinning, it’s a balance disorder (many possible causes—vestibular, neurological, proprioceptive, psychological). The answer changes treatment.

Can anxiety cause dizziness that feels like vertigo?

Anxiety can cause dizziness, lightheadedness, and balance problems. But true vertigo (spinning sensation) is less common from anxiety alone. If you have anxiety-related dizziness, treating the anxiety helps. If you have true vertigo, treating anxiety alone won’t help—you need vestibular or neurological evaluation.

My balance tests are normal but I still feel unsteady. What’s wrong?

Normal tests don’t rule out all problems. PPPD causes chronic unsteadiness despite normal objective balance tests—the problem is brain sensitivity, not structural damage. Anxiety-related dizziness can also have normal tests. Sometimes repeat testing or specialized testing (CDP) needed. Sometimes the answer is psychological/rehabilitative rather than structural.

Do all balance problems need medication?

No. Many balance disorders (vestibular rehabilitation needs, cerebellar dysfunction, proprioceptive loss) respond better to physical therapy than medication. Medication helps acute symptoms but rehabilitation provides long-term solutions for many balance problems.

Can neck problems cause balance problems?

Neck pathology can contribute to balance dysfunction through proprioceptive disruption. But most patients told they have “cervical vertigo” actually have inner ear or other problems. Genuine cervical contribution exists but is less common than typically blamed. Requires imaging and careful assessment to confirm.

How long does balance disorder recovery take?

Varies tremendously. BPPV resolves in days. Vestibular neuritis takes weeks to months. Chronic balance disorders may improve over months with rehabilitation. PPPD can take months to years of cognitive-behavioral therapy. Timeframe depends on underlying cause and rehabilitation commitment.

Assessment Challenges and Diagnostic Pitfalls

Overlooking psychological factors: Many patients with balance problems have significant anxiety. This isn’t just secondary anxiety from experiencing balance dysfunction—sometimes anxiety is primary and causes or worsens symptoms. Taking psychological history and addressing anxiety improves outcomes.

Over-investigating: Expensive imaging and testing sometimes ordered for straightforward cases. A patient with clear BPPV on clinical exam doesn’t need MRI. A patient with classic peripheral vestibular loss pattern doesn’t need advanced vestibular testing immediately. Let clinical assessment guide testing.

Missing central causes: Conversely, some patients with red flags (progressive symptoms, vertical nystagmus, other neurological signs) aren’t imaged urgently enough. Red flags warrant MRI or advanced assessment to rule out central causes.

Medication misuse: Long-term vestibular suppressants for conditions not needing them (BPPV, for example). Medications should match diagnosis—BPPV needs maneuver not meds; vestibular neuritis needs rehabilitation not suppressants; anxiety needs treatment not vestibular meds.