Have you ever felt dizzy, lightheaded, or as if the room is spinning around you? If the feeling happens often, it could be a sign of a balance problem. Balance problems can make you feel unsteady. You may also have blurred vision, confusion, and disorientation. They are one cause of falls and fall-related injuries, such as a hip fracture (broken hip).

Some balance problems are due to problems in the inner ear. Others may involve another part of the body, such as the brain or the heart. Aging, infections, head injury, certain medicines, or problems with blood circulation may also cause balance problems.

It is important to see your doctor about balance problems. They can be a sign of other health problems, such as an ear infection or a stroke. Your doctor may send you to a specialist for a diagnosis. You may need a hearing test, blood tests, or imaging studies of your head and brain. Other possible tests look at your eye movements, and how your body responds to movement.

In some cases, treating the illness that is causing the disorder will help with the balance problem. Exercises, a change in diet, and some medicines also can help.

A balance disorder is a condition that makes you feel unsteady or dizzy. If you are standing, sitting, or lying down, you might feel as if you are moving, spinning, or floating. If you are walking, you might suddenly feel as if you are tipping over.

Everyone has a dizzy spell now and then, but the term “dizziness” can mean different things to different people. For one person, dizziness might mean a fleeting feeling of faintness, while for another it could be an intense sensation of spinning (vertigo) that lasts a long time.

About 15 percent of American adults (33 million) had a balance or dizziness problem in 2008. Balance disorders can be caused by certain health conditions, medications, or a problem in the inner ear or the brain. A balance disorder can profoundly affect daily activities and cause psychological and emotional hardship.

Your sense of balance relies on a series of signals to your brain from several organs and structures in your body, specifically your eyes, ears, and the muscles and touch sensors in your legs. The part of the ear that assists in balance is known as the vestibular system, or the labyrinth, a maze-like structure in your inner ear made of bone and soft tissue.

Within the labyrinth are structures known as semicircular canals. The semicircular canals contain three fluid-filled ducts, which form loops arranged roughly at right angles to one another. They tell your brain when your head rotates. Inside each canal is a gelatin-like structure called the cupula [KEW-pyew-lah], stretched like a thick sail that blocks off one end of each canal. The cupula sits on a cluster of sensory hair cells. Each hair cell has tiny, thin extensions called stereocilia that protrude into the cupula.

When you turn your head, fluid inside the semicircular canals moves, causing the cupulae to flex or billow like sails in the wind, which in turn bends the stereocilia. This bending creates a nerve signal that is sent to your brain to tell it which way your head has turned.

Between the semicircular canals and the cochlea (a snail-shaped, fluid-filled structure in the inner ear) lie two otolithic [oh-toe-LITH-ic] organs: fluid-filled pouches called the utricle [YOU-trih-cull] and the saccule [SACK-kewl]. These organs tell your brain the position of your head with respect to gravity, such as whether you are sitting up, leaning back, or lying down, as well as any direction your head might be moving, such as side to side, up or down, forward or backward.

The utricle and the saccule also have sensory hair cells lining the floor or wall of each organ, with stereocilia extending into an overlying gel-like layer. Here, the gel contains tiny, dense grains of calcium carbonate called otoconia [oh-toe-CONE-ee-ah]. Whatever the position of your head, gravity pulls on these grains, which then move the stereocilia to signal your head's position to your brain. Any head movement creates a signal that tells your brain about the change in head position.

When you move, your vestibular system detects mechanical forces, including gravity, that stimulate the semicircular canals and the otolithic organs. These organs work with other sensory systems in your body, such as your vision and your musculoskeletal sensory system, to control the position of your body at rest or in motion. This helps you maintain stable posture and keep your balance when you're walking or running. It also helps you keep a stable visual focus on objects when your body changes position.

When the signals from any of these sensory systems malfunction, you can have problems with your sense of balance, including dizziness or vertigo. If you have additional problems with motor control, such as weakness, slowness, tremor, or rigidity, you can lose your ability to recover properly from imbalance. This raises the risk of falling and injury.

Along with audition, the inner ear is responsible for encoding information about equilibrium , the sense of balance. A similar mechanoreceptor—a hair cell with stereocilia—senses head position, head movement, and whether our bodies are in motion. These cells are located within the vestibule of the inner ear. Head position is sensed by the utricle and saccule , whereas head movement is sensed by the semicircular canals . The neural signals generated in the vestibular ganglion are transmitted through the vestibulocochlear nerve to the brain stem and cerebellum.

The utricle and saccule are both largely composed of macula tissue (plural = maculae). The macula is composed of hair cells surrounded by support cells. The stereocilia of the hair cells extend into a viscous gel called the otolithic membrane (Figure). On top of the otolithic membrane is a layer of calcium carbonate crystals, called otoliths. The otoliths essentially make the otolithic membrane top-heavy. The otolithic membrane moves separately from the macula in response to head movements. Tilting the head causes the otolithic membrane to slide over the macula in the direction of gravity. The moving otolithic membrane, in turn, bends the sterocilia, causing some hair cells to depolarize as others hyperpolarize. The exact position of the head is interpreted by the brain based on the pattern of hair-cell depolarization.

The semicircular canals are three ring-like extensions of the vestibule. One is oriented in the horizontal plane, whereas the other two are oriented in the vertical plane. The anterior and posterior vertical canals are oriented at approximately 45 degrees relative to the sagittal plane (Figure). The base of each semicircular canal, where it meets with the vestibule, connects to an enlarged region known as the ampulla . The ampulla contains the hair cells that respond to rotational movement, such as turning the head while saying “no.” The stereocilia of these hair cells extend into the cupula , a membrane that attaches to the top of the ampulla. As the head rotates in a plane parallel to the semicircular canal, the fluid lags, deflecting the cupula in the direction opposite to the head movement. The semicircular canals contain several ampullae, with some oriented horizontally and others oriented vertically. By comparing the relative movements of both the horizontal and vertical ampullae, the vestibular system can detect the direction of most head movements within three-dimensional (3-D) space.

Review

A mechanoreceptor similar to a hair cell with stereocilia—senses head position, head movement, and whether our bodies are in motion. Head position is sensed by the utricle and saccule, whereas head movement is sensed by the semicircular canals. The neural signals generated in the vestibular ganglion are transmitted through the vestibulocochlear nerve to the brain stem and cerebellum.

The utricle and saccule are both largely composed of macula tissue (plural = maculae). The stereocilia of the macula hair cells extend into a viscous gel called the otolithic membrane. On top of the otolithic membrane is a layer of calcium carbonate crystals, called otoliths. Tilting the head causes the otolithic membrane to slide over the macula in the direction of gravity. The moving otolithic membrane, in turn, bends the sterocilia, causing some hair cells to depolarize as others hyperpolarize.

The semicircular canals are three ring-like extensions of the vestibule. The base of each semicircular canal, where it meets with the vestibule, connects to an enlarged region known as the ampulla. The ampulla contains the hair cells that respond to rotational movement. The stereocilia of these hair cells extend into the cupula, a membrane that attaches to the top of the ampulla. The semicircular canals contain several ampullae, with some oriented horizontally and others oriented vertically. By comparing the relative movements of both the horizontal and vertical ampullae, the vestibular system can detect the direction of most head movements within three-dimensional (3-D) space.

Most people feel dizzy now and then. Kids, like adults, may occasionally feel lightheaded or unsteady. But if such feelings repeat or interfere with everyday life, it could be a sign of a balance disorder.

Most balance problems are temporary and easy to treat. But these problems may also signal a more serious condition that could have a lasting impact. Learn to recognize the signs of dizziness or balance problems that may warrant a trip to a doctor.

Experts have long suspected that dizziness and balance problems are often overlooked and untreated, but the scope of the problem wasn’t fully understood. That’s why NIH supported the largest national survey to date to uncover information about these disorders in children. The study included data on nearly 11,000 kids, ages 3 to 17.

The researchers found that more than 1 in 20 kids in the U.S. had a dizziness or balance problem, and only one-third of them received treatment in the previous year. “The findings suggest that dizziness and balance problems are fairly common among children,” says Dr. James F. Battey, Jr., a pediatrician and director of NIH’s National Institute on Deafness and Other Communication Disorders.

Our sense of balance is a complex process. It’s managed by signals between the brain, ears, eyes, and sensors in the joints and other body parts. This intricate system helps your body monitor and maintain its position as you move throughout the day, without you even having to think about it. But if any of these many sensory signals go wrong, it can weaken your sense of balance.

Balance disorders can make you stagger when walking. You might teeter or fall when trying to stand. Affected people might feel like they themselves or the world around them is spinning or moving—a condition known as vertigo. Other symptoms can include blurred vision, vomiting, diarrhea, confusion, and anxiety.

Common causes of balance problems in children range from ear infections, severe headaches, and certain medications to more serious neurological disorders, head or neck injuries, and genetic conditions. In many cases, the study’s researchers found, an underlying cause wasn’t reported.

Balance disorders can be difficult to recognize and understand. They can be especially hard to diagnose in young children. Kids may not know the right words to describe their symptoms. Affected children may talk about a “spinning feeling.” They may say their tummy or head feels bad or weird. They may walk unsteadily or seem clumsy.

“Parents who notice dizziness and balance problems in their children should consult a health care provider to rule out a serious underlying condition,” Battey says.

Your child’s pediatrician will likely ask questions about when the symptoms first appeared, how long they last, how often they occur, and what medications the child is taking. Your child’s eyes and ears will be examined, and hearing and balance may be tested. You may be referred to a specialist, such as an otolaryngologist—a doctor with expertise in the ear, nose, and throat.

Treatment will depend on the underlying cause. The good news is that most dizziness and balance problems in children are temporary and treatable. Still, it’s important to check with a health professional if you notice any problems.

Tell Your Doctor

Dizziness and balance problems may be hard to spot in children. Younger kids may lack the vocabulary to describe their symptoms. Talk with a health care provider if your child:

• falls frequently.
• seems unsteady upon standing or walking.
• feels as if the room is spinning around him/her.
• feels as if moving when standing or sitting still.
• feels as if she’s falling.
• feels lightheaded, or as if he might faint.
• says that vision becomes blurred.

There are more than a dozen different balance disorders. Some of the most common are:

• Benign paroxysmal positional vertigo (BPPV) or positional vertigo: A brief, intense episode of vertigo triggered by a specific change in the position of the head. You might feel as if you're spinning when you bend down to look under something, tilt your head to look up or over your shoulder, or roll over in bed. BPPV occurs when loose otoconia tumble into one of the semicircular canals and affect how the cupula works. This keeps the cupula from flexing properly, sending incorrect information about your head's position to your brain, and causing vertigo. BPPV can result from a head injury, or can develop just from getting older.
• Labyrinthitis: An infection or inflammation of the inner ear that causes dizziness and loss of balance. It is often associated with an upper respiratory infection, such as the flu.
• Ménière's disease: Episodes of vertigo, hearing loss, tinnitus (a ringing or buzzing in the ear), and a feeling of fullness in the ear. It may be associated with a change in fluid volume within parts of the labyrinth, but the cause or causes are still unknown. For more information, read the NIDCD fact sheet Ménière's Disease.
• Vestibular neuronitis: An inflammation of the vestibular nerve that can be caused by a virus, and primarily causes vertigo.
• Perilymph fistula: A leakage of inner ear fluid into the middle ear. It causes unsteadiness that usually increases with activity, along with dizziness and nausea. Perilymph fistula can occur after a head injury, dramatic changes in air pressure (such as when scuba diving), physical exertion, ear surgery, or chronic ear infections. Some people are born with perilymph fistula.
• Mal de Debarquement syndrome (MdDS): A feeling of continuously rocking, swaying, or bobbing, typically after an ocean cruise or other sea travel, or even after prolonged running on a treadmill. Usually the symptoms go away within a few hours or days after you reach land or stop using the treadmill. Severe cases, however, can last months or even years, and the cause remains unknown.

Causes of balance problems include medications, ear infection, a head injury, or anything else that affects the inner ear or brain. Low blood pressure can lead to dizziness when you stand up too quickly. Problems that affect the skeletal or visual systems, such as arthritis or eye muscle imbalance, can also cause balance disorders. Your risk of having balance problems increases as you get older.

Unfortunately, many balance disorders start suddenly and with no obvious cause.

If you have a balance disorder, your symptoms might include:

• Dizziness or vertigo (a spinning sensation).
• Falling or feeling as if you are going to fall.
• Staggering when you try to walk.
• Lightheadedness, faintness, or a floating sensation.
• Blurred vision.
• Confusion or disorientation.

Other symptoms might include nausea and vomiting; diarrhea; changes in heart rate and blood pressure; and fear, anxiety, or panic. Symptoms may come and go over short time periods or last for a long time, and can lead to fatigue and depression.

To help you decide whether to seek medical help for dizziness or balance problems, ask yourself the following questions. If you answer “yes” to any of these questions, talk to your doctor:

• Do I feel unsteady?
• Do I feel as if the room is spinning around me, even for a very brief time?
• Do I feel as if I'm moving when I know I'm sitting or standing still?
• Do I lose my balance and fall?
• Do I feel as if I'm falling?
• Do I feel lightheaded or as if I might faint?
• Do I have blurred vision?
• Do I ever feel disoriented—losing my sense of time or location?

Diagnosis of a balance disorder is difficult. To find out if you have a balance problem, your primary doctor may suggest that you see an otolaryngologist and an audiologist. An otolaryngologist is a physician and surgeon who specializes in diseases and disorders of the ear, nose, neck, and throat. An audiologist is a clinician who specializes in the function of the hearing and vestibular systems.

You may be asked to participate in a hearing examination, blood tests, a video nystagmogram (a test that measures eye movements and the muscles that control them), or imaging studies of your head and brain. Another possible test is called posturography. For this test, you stand on a special movable platform in front of a patterned screen.

Posturography measures how well you can maintain steady balance during different platform conditions, such as standing on an unfixed, movable surface. Other tests, such as rotational chair testing, brisk head-shaking testing, or even tests that measure eye or neck muscle responses to brief clicks of sound, may also be performed. The vestibular system is complex, so multiple tests may be needed to best evaluate the cause of your balance problem.

You can help your doctor make a diagnosis and determine a treatment plan by answering the questions below. Be prepared to discuss this information during your appointment.

1. The best way I can describe my dizziness or balance problem is:
   • Is there a spinning sensation, and if so, which way does the room spin?
   • Is the dizziness/spinning caused by any specific motion or does it occur even when sitting or lying still?
   • Are there any other symptoms that occur at the same time as the dizziness/spinning, such as hearing loss, tinnitus, a feeling of pressure in one or both ears, or a headache?
   • Does anything seem to help the dizziness/spinning?
2. How often do I feel dizzy or have trouble keeping my balance? How long do the dizziness or spinning episodes last (seconds, minutes, hours, days)?
3. Have I ever fallen?
   • When did I fall?
   • Where did I fall?
   • Under what conditions did I fall?
   • How often have I fallen?
4. These are the medicines I take. Include all prescription medications; all over-the-counter medicine, such as aspirin, antihistamines, or sleep aids; and all vitamin supplements and alternative or homeopathic remedies:
   • Name of medicine or supplement: ______________________.
   • How much (milligrams) _____ and how often (times) ______ per day.
   • The condition I take this medicine for is: __________________________.

The first thing an otolaryngologist will do if you have a balance problem is determine if another health condition or a medication is to blame. If so, your doctor will treat the condition, suggest a different medication, or refer you to a specialist if the condition is outside his or her expertise.

If you have BPPV, your otolaryngologist or audiologist might perform a series of simple movements, such as the Epley maneuver, to help dislodge the otoconia from the semicircular canal. In many cases, one session works; other people need the procedure several times to relieve their dizziness.

If you are diagnosed with Ménière's disease, your otolaryngologist may recommend that you make some changes to your diet and, if you are a smoker, that you stop smoking. Anti-vertigo or anti-nausea medications may relieve your symptoms, but they can also make you drowsy. Other medications, such as gentamicin (an antibiotic) or corticosteroids may be used. Although gentamicin may reduce dizziness better than corticosteroids, it occasionally causes permanent hearing loss. In some severe cases of Ménière's disease, surgery on the vestibular organs may be needed.

Some people with a balance disorder may not be able to fully relieve their dizziness and will need to find ways to cope with it. A vestibular rehabilitation therapist can help you develop an individualized treatment plan.

Talk to your doctor about whether it's safe to drive, and about ways to lower your risk of falling and getting hurt during daily activities, such as when you walk up or down stairs, use the bathroom, or exercise. To reduce your risk of injury from dizziness, avoid walking in the dark. Wear low-heeled shoes or walking shoes outdoors. If necessary, use a cane or walker and modify conditions at your home and workplace, such as adding handrails.

You need your sense of balance to stand, walk, bend down, drive, and more. If it gets disrupted, you may struggle to work, study, or even do simple daily activities. Balance problems also increase the risk of dangerous falls.

“Balance is really your sixth sense,” says Dr. David Newman-Toker, a neurologist at Johns Hopkins University. “But we’re not usually aware of it, unless it’s broken.”

Many things can affect your balance. Being hungry or dehydrated may make you feel lightheaded. Some medications can make you feel dizzy. Health problems that affect your inner ear or brain can also throw off your balance. These may include infection, stroke, or a tumor.

Usually, a disruption in balance is temporary. But some things can cause long-term balance problems. So how do you know when to be concerned?

“If your symptoms are severe, or last for a long time, that’s an indication to have things checked out,” says Dr. Michael Hoa, an ear, nose, and throat specialist at NIH. “Pay attention to things that aren’t normal for you.”

You may feel like you’re moving, spinning, or floating, even if you’re sitting or lying still. Or you could feel like you’re suddenly tipping over while you’re walking. You might have blurred vision or feel confused or disoriented.

Pinpointing the Problem

Tiny organs in your inner ear form the core of your balance system. They communicate with your brain to give you a sense of your body’s position.

“But your balance system isn’t just your inner ear,” Hoa says. “It’s input from your eyes. It’s your muscles, joints, and spine. It’s your vision.”

That makes balance disorders tricky to diagnose. “A change in any part of the system could contribute to changes in your balance,” he says. “Sometimes that makes it hard to distinguish one balance disorder from another.”

A new balance problem can sometimes signal a medical emergency, like a stroke. So it’s important to get symptoms checked out as soon as possible.

“The most important things to tell your health care provider are the timing and triggers for your symptoms,” says Newman-Toker. This will help them narrow down the possible cause.

Common Causes of Balance Problems

Identifying what’s causing a balance problem can be complicated. Several disorders have similar symptoms.

An infection or inflammation of the inner ear can trigger dizziness and loss of balance. This is called labyrinthitis. Inflammation can also affect the nerve that sends signals about balance to the brain. This is called vestibular neuritis.

The most common cause of dizzy spells is called benign paroxysmal positional vertigo, or BPPV. This occurs when tiny crystals in the inner ear fall out of place. BPPV can cause a brief, intense sense of vertigo triggered by certain changes in the position of your head. The spells last less than a minute.

A less common, but recurrent, cause of balance problems is Ménière’s disease. This can cause vertigo, hearing loss, and a ringing or buzzing sensation in the ear. It’s not known what causes this condition. But people living with it often have extra fluid in their inner ear.

To determine what’s causing your symptoms, your health care provider can do different tests. These include a hearing exam, blood tests, or tests to measure your eye movements. If these tests can’t rule out a stroke, you may also need an MRI scan.

Newman-Toker’s team is experimenting with goggles that measure eye movements automatically. They’re testing whether the goggles can help doctors in the emergency department make better diagnoses.

Because some balance disorders can look similar, people may not always get the right diagnosis and treatment on the first try, says Newman-Toker. You may need to visit another doctor or try different treatments before you feel better.

Finding What Works

Some balance disorders have straightforward treatments. But others can be tricky. For BPPV, a trained health care provider can perform a series of simple head movements. These move the loose crystals back in place.

Ménière’s disease is harder to treat. Lifestyle changes like stopping smoking and eating less salt can sometimes reduce symptoms. New drugs are now being tested to treat Ménière’s disease in clinical studies.

Hoa’s lab is trying to identify possible causes of Ménière’s disease. They’re looking at how genes, proteins, and the body’s disease defense system (the immune system) may be involved. They suspect that what’s currently called Ménière’s disease may be several different conditions. Pinpointing the differences may lead to more personalized treatments.

But currently, few effective drugs exist for long-term balance problems, says Dr. Anat Lubetzky, a physical therapist at New York University. “For many people, the solution to a balance problem is balance rehabilitation.” Rehabilitation teaches you ways to adapt to dizzy spells. It also focuses on strengthening muscles and preventing falls.

“People with balance disorders can enter a vicious cycle of the fear of falling,” Lubetzky says. “They may avoid activity, which can then create muscle and bone problems.”

That, in turn, can increase the risk of more falls. “You have to gain your confidence back,” she says.

Lubetzky is researching the use of virtual reality, or VR, to better understand and treat balance disorders. Many people with balance disorders struggle in environments with a lot of sights and sounds. So her lab creates virtual scenes, like subway stations, for rehab sessions. These scenes let people practice walking in small virtual crowds.

As people build their skills, the scenes can get busier and noisier. The team hopes that these programs will help people regain their confidence in busy environments without leaving the safety of the clinic.

Whether it’s rehab, medications, or other treatments, it may take time to find something that works for you.

“If things don’t go how you’ve been told to expect them to, be aware that you might actually not have the right diagnosis,” Newman-Toker says. You may need to go back to your health care provider or see a specialist.

It may also take time to gain your confidence back. In the meantime, anyone living with a balance disorder—either temporarily or permanently—can also do simple things at home to prevent falls and accidents. See the Wise Choices box for tips.

Living With a Balance Disorder

To help prevent falls and other accidents:

• Avoid walking in the dark, either inside or outside.
• Wear low-heeled shoes or walking shoes.
• Use a cane or walker, if necessary.
• Add handrails to stairwells and bathrooms in your home.
• Stay physically active to improve your balance and strength. A physical therapist can help you learn to exercise safely.
• Talk with your health care provider about whether it’s safe to drive.

Scientists supported by the National Institute on Deafness and Other Communication Disorders (NIDCD) are studying animal ears to learn if inner-ear structures that help with balance but are destroyed by aging, medications, infections, or trauma can someday be regrown in people with balance problems. Other NIDCD-supported scientists are testing vestibular prostheses—miniature devices that may be worn outside the body or implanted into the ear to regulate the function of balance organs in the inner ear and ease dizziness. Some of these devices are being tested on volunteers in clinical trials, and others are still being developed. Visit the NIH Clinical Research Trials and You website to read about these and other clinical trials that are recruiting volunteers.

NIDCD-funded scientists are also working to develop much-needed tests to appropriately diagnose balance disorders. Standardized tests will help doctors determine the best way to help individuals restore their sense of balance and quality of life. These tests will also help us understand how many people suffer from balance disorders, and track whether the sense of balance is restored following treatment.