Balance disorders are common and may significantly impact upon quality of life and independence. Impaired balance may result in falls with resulting morbidity and mortality, particularly in older people.
Summary
Epidemiology
Estimates of dizziness and vertigo in the community range from 17% to 30% and from 3% to 10%, respectively.[1] The prevalence of balance problems at age 70 years is reported to be 36% in women and 29% in men.[2]
Symptoms of dizziness or vertigo may constitute between 1% and 15.5% of primary care consultations.[3] Among the most commonly reported etiologies in primary care are vestibular/peripheral (5.4% to 42.1%), benign paroxysmal positional vertigo (4.3% to 39.5%), cardiovascular disease (3.8% to 56.8%), psychogenic (1.8% to 21.6%), Meniere disease (1.4% to 2.7%), neurologic disease (1.4% to 11.4%) vestibular neuritis (0.6% to 24%), and no clear diagnosis (up to 80.2%).[3]
Citations
Goebel JA. 2015 Equilibrium Committee Amendment to the 1995 AAO-HNS guidelines for the definition of Ménière's disease. Otolaryngol Head Neck Surg. 2016 Mar;154(3):403-4.[Abstract]
Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017 Mar;156(suppl 3):S1-47.[Abstract][Full Text]
Expert Panel on Neurologic Imaging:, Sharma A, Kirsch CFE, et al. ACR appropriateness criteria(®) hearing loss and/or vertigo. J Am Coll Radiol. 2018 Nov;15(11s):S321-31.[Abstract][Full Text]
Expert Panel on Neurologic Imaging:, Salmela MB, Mortazavi S, et al. ACR appropriateness criteria(®) cerebrovascular disease. J Am Coll Radiol. 2017 May;14(5s):S34-61.[Abstract][Full Text]
1. Murdin L, Schilder AG. Epidemiology of balance symptoms and disorders in the community: a systematic review. Otol Neurotol. 2015 Mar;36(3):387-92.[Abstract]
2. Jonsson R, Sixt E, Landahl S, et al. Prevalence of dizziness and vertigo in an urban elderly population. J Vestib Res. 2004;14(1):47-52.[Abstract]
3. Bösner S, Schwarm S, Grevenrath P, et al. Prevalence, aetiologies and prognosis of the symptom dizziness in primary care - a systematic review. BMC Fam Pract. 2018 Feb 20;19(1):33.[Abstract][Full Text]
4. Strupp M, Bisdorff A, Furman J, et al. Acute unilateral vestibulopathy/vestibular neuritis: diagnostic criteria. J Vestib Res. 2022;32(5):389-406.[Abstract][Full Text]
5. King S, Dahlem K, Karmali F, et al. Imbalance and dizziness caused by unilateral vestibular schwannomas correlate with vestibulo-ocular reflex precision and bias. J Neurophysiol. 2022 Feb 1;127(2):596-606.[Abstract][Full Text]
6. Withrow DR, Devesa SS, Deapen D, et al. Nonmalignant meningioma and vestibular schwannoma incidence trends in the United States, 2004-2017. Cancer. 2021 Oct 1;127(19):3579-90.[Abstract][Full Text]
7. Baloh RW, Jacobson K, Winder T. Drop attacks with Meniere's syndrome. Ann Neurol. 1990 Sep;28(3):384-7.[Abstract]
8. Goebel JA. 2015 Equilibrium Committee Amendment to the 1995 AAO-HNS guidelines for the definition of Ménière's disease. Otolaryngol Head Neck Surg. 2016 Mar;154(3):403-4.[Abstract]
9. Strupp M, Brandt T. Central vertigo. Otorhinolaryngol Clin Int J. 2012;4(2):71-6.[Full Text]
10. Alpini D, Caputo D, Pugnetti L, et al. Vertigo and multiple sclerosis: aspects of differential diagnosis. Neurol Sci. 2001 Nov;22 Suppl 2:S84-7.[Abstract]
11. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017 Mar;156(suppl 3):S1-47.[Abstract][Full Text]
12. Brantberg K, Ishiyama A, Baloh RW. Drop attacks secondary to superior canal dehiscence syndrome. Neurology. 2005 Jun 28;64(12):2126-8.[Abstract]
13. Lee SH, Kim SH, Kim JM, et al. Vestibular dysfunction in Wernicke's encephalopathy: predominant impairment of the horizontal semicircular canals. Front Neurol. 2018 Mar 12:9:141.[Abstract][Full Text]
14. Sowula K, Składzień J, Szaleniec J, et al. Otolaryngological symptoms in patients treated for tick-borne diseases. Otolaryngol Pol. 2018 Feb 28;72(1):30-4.[Abstract][Full Text]
15. Buniel MC, Geelan-Hansen K, Weber PC, et al. Immunosuppressive therapy for autoimmune inner ear disease. Immunotherapy. 2009 May;1(3):425-34.[Abstract][Full Text]
16. Van Samkar A, Poulsen MNF, Bienfait HP, et al. Acute cerebellitis in adults: a case report and review of the literature. BMC Res Notes. 2017 Nov 22;10(1):610.[Abstract][Full Text]
17. Manto MU. The wide spectrum of spinocerebellar ataxias (SCAs). Cerebellum. 2005;4(1):2-6.[Abstract]
18. Sullivan R, Yau WY, O'Connor E, et al. Spinocerebellar ataxia: an update. J Neurol. 2019 Feb;266(2):533-44.[Abstract][Full Text]
19. Pothier DD, Rutka JA, Ranalli PJ. Double impairment: clinical identification of 33 cases of cerebellar ataxia with bilateral vestibulopathy. Otolaryngol Head Neck Surg. 2012 May;146(5):804-8.[Abstract]
20. Brantberg K, Trees N, Baloh RW. Migraine-associated vertigo. Acta Otolaryngol. 2005 Mar;125(3):276-9.[Abstract]
21. Headache Classification Committee of the International Headache Society (IHS) the international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.[Full Text]
22. Hain TC, Hanna PA, Rheinberger MA. Mal de debarquement. Arch Otolaryngol Head Neck Surg. 1999 Jun;125(6):615-20.[Abstract]
23. McGinley MP, Goldschmidt CH, Rae-Grant AD. Diagnosis and treatment of multiple sclerosis: a review. JAMA. 2021 Feb 23;325(8):765-79. [Abstract]
24. Boonstra TA, van der Kooij H, Munneke M, et al. Gait disorders and balance disturbances in Parkinson's disease: clinical update and pathophysiology. Curr Opin Neurol. 2008 Aug;21(4):461-71.[Abstract]
25. Nikaido Y, Urakami H, Akisue T, et al. Associations among falls, gait variability, and balance function in idiopathic normal pressure hydrocephalus. Clin Neurol Neurosurg. 2019 Aug;183:105385.[Abstract]
26. Höllerhage M. Secondary parkinsonism due to drugs, vascular lesions, tumors, trauma, and other insults. Int Rev Neurobiol. 2019;149:377-418.[Abstract]
27. Raccagni C, Nonnekes J, Bloem BR, et al. Gait and postural disorders in parkinsonism: a clinical approach. J Neurol. 2020 Nov;267(11):3169-76.[Abstract][Full Text]
28. Hughes RA. Peripheral neuropathy. BMJ. 2002 Feb 23;324(7335):466-9.[Full Text]
29. Hanewinckel R, van Oijen M, Ikram MA, et al. The epidemiology and risk factors of chronic polyneuropathy. Eur J Epidemiol. 2016 Jan;31(1):5-20.[Abstract][Full Text]
30. Wakerley BR, Uncini A, Yuki N, et al. Guillain-Barré and Miller Fisher syndromes--new diagnostic classification. Nat Rev Neurol. 2014 Sep;10(9):537-44.[Abstract]
31. Coarelli G, Wirth T, Tranchant C, et al. The inherited cerebellar ataxias: an update. J Neurol. 2023 Jan;270(1):208-22.[Abstract][Full Text]
32. Sirven JI, Fife TD, Wingerchuk DM, et al. Second-generation antiepileptic drugs' impact on balance: a meta-analysis. Mayo Clin Proc. 2007 Jan;82(1):40-7.[Abstract]
33. Lanvers-Kaminsky C, Zehnhoff-Dinnesen AA, Parfitt R, et al. Drug-induced ototoxicity: mechanisms, pharmacogenetics, and protective strategies. Clin Pharmacol Ther. 2017 Apr;101(4):491-500.[Abstract]
34. Lee H, Baloh RW. Sudden deafness in vertebrobasilar ischemia: clinical features, vascular topographical patterns and long-term outcome. J Neurol Sci. 2005 Jan 15;228(1):99-104.[Abstract]
35. Gottlieb M, Peksa GD, Carlson JN. Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome. Cochrane Database Syst Rev. 2023 Nov 2;11(11):CD015089.[Abstract][Full Text]
36. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10.[Abstract][Full Text]
37. Saber Tehrani AS, Kattah JC, Mantokoudis G, et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014 Jul 8;83(2):169-73.[Abstract]
38. Furman JM, Becker JT. Vestibular responses in Wernicke's encephalopathy. Ann Neurol. 1989 Nov;26(5):669-74.[Abstract]
39. Newman-Toker DE, Dy FJ, Stanton VA, et al. How often is dizziness from primary cardiovascular disease true vertigo? A systematic review. J Gen Intern Med. 2008 Dec;23(12):2087-94.[Abstract][Full Text]
40. Weber KP, Aw ST, Todd MJ, et al. Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. Neurology. 2008 Feb 5;70(6):454-63.[Abstract]
41. Asawavichiangianda S, Fujimoto M, Mai M, et al. Significance of head-shaking nystagmus in the evaluation of the dizzy patient. Acta Otolaryngol Suppl. 1999;540:27-33.[Abstract]
42. Gonçalves DU, Felipe L, Lima TM. Interpretation and use of caloric testing. Braz J Otorhinolaryngol. 2008 May-Jun;74(3):440-6.[Abstract][Full Text]
43. Musat GC, Tataru CP, Musat O, et al. Ocular movement examination in peripheral vestibular disorders as a tool to improve diagnosis: a literature review. Medicina (Kaunas). 2024 Oct 11;60(10):1665.[Abstract][Full Text]
44. Expert Panel on Neurologic Imaging:, Sharma A, Kirsch CFE, et al. ACR appropriateness criteria(®) hearing loss and/or vertigo. J Am Coll Radiol. 2018 Nov;15(11s):S321-31.[Abstract][Full Text]
45. Expert Panel on Neurologic Imaging:, Salmela MB, Mortazavi S, et al. ACR appropriateness criteria(®) cerebrovascular disease. J Am Coll Radiol. 2017 May;14(5s):S34-61.[Abstract][Full Text]
46. Timmer FC, Zhou G, Guinan JJ, et al. Vestibular evoked myogenic potential (VEMP) in patients with Meniere's disease with drop attacks. Laryngoscope. 2006 May;116(5):776-9.[Abstract]
47. Chung SP, Kim SW, Yoo IS, et al. Magnetic resonance imaging as a diagnostic adjunct to Wernicke encephalopathy in the ED. Am J Emerg Med. 2003 Oct;21(6):497-502.[Abstract]
48. Polensek SH, Tusa RJ. Nystagmus during attacks of vestibular migraine: an aid in diagnosis. Audiol Neurootol. 2010;15(4):241-6.[Abstract]
49. Felipe L, Cavazos R. Caloric stimulation with water and air: responses by age and gender. Iran J Otorhinolaryngol. 2021 Mar;33(115):71-7.[Abstract][Full Text]
50. Fife TD, Colebatch JG, Kerber KA, et al. Practice guideline: cervical and ocular vestibular evoked myogenic potential testing: report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology. Neurology. 2017 Nov 28;89(22):2288-96.[Abstract][Full Text]
51. Welgampola MS, Myrie OA, Minor LB, et al. Vestibular-evoked myogenic potential thresholds normalize on plugging superior canal dehiscence. Neurology. 2008 Feb 5;70(6):464-72.[Abstract]
52. Curtin HD. Superior semicircular canal dehiscence syndrome and multi-detector ROW CT. Radiology. 2003 Feb;226(2):312-4.[Abstract]
53. Baloh RW. Paraneoplastic cerebellar disorders. Otolaryngol Head Neck Surg. 1995 Jan;112(1):125-7.[Abstract]
54. Harding AE, Matthews S, Jones S, et al. Spinocerebellar degeneration associated with a selective defect of vitamin E absorption. N Engl J Med. 1985 Jul 4;313(1):32-5.[Abstract]
55. Elble RJ, Cousins R, Leffler K, et al. Gait initiation by patients with lower-half parkinsonism. Brain. 1996 Oct;119 (Pt 5):1705-16.[Abstract]
56. Teive HA, Germiniani FM, Munhoz RP. Charcot and vascular parkinsonism. Arq Neuropsiquiatr. 2017 Mar;75(3):195-6.[Abstract][Full Text]
57. Curran T, Lang AE. Parkinsonian syndromes associated with hydrocephalus: case reports, a review of the literature, and pathophysiological hypotheses. Mov Disord. 1994 Sep;9(5):508-20.[Abstract]
58. Polyzoidis KS, McQueen JD, Rajput AH, et al. Parkinsonism as a manifestation of brain tumor. Surg Neurol. 1985 Jan;23(1):59-63.[Abstract]
59. Hageman AT, Horstink MW. Parkinsonism due to a subdural hematoma. Mov Disord. 1994 Jan;9(1):107-8.[Abstract]
60. Fross RD, Daube JR. Neuropathy in the Miller Fisher syndrome: clinical and electrophysiologic findings. Neurology. 1987 Sep;37(9):1493-8.[Abstract]
61. Willison HJ, Veitch J, Paterson G, et al. Miller Fisher syndrome is associated with serum antibodies to GQ1b ganglioside. J Neurol Neurosurg Psychiatry. 1993 Feb;56(2):204-6.[Abstract][Full Text]
62. Chiba A, Kusunoki S, Obata H, et al. Serum anti-GQ1b IgG antibody is associated with ophthalmoplegia in Miller Fisher syndrome and Guillain-Barre syndrome: clinical and immunohistochemical studies. Neurology. 1993 Oct;43(10):1911-7.[Abstract]
63. Ropper AH, Wijdicks EFM, Truax BT. Guillain-Barre syndrome. Philadelphia, PA: F.A. Davis; 1991.
64. Sellner J, Boggild M, Clanet M, et al. EFNS guidelines on diagnosis and management of neuromyelitis optica. Eur J Neurol. 2010 Aug;17(8):1019-32.[Abstract][Full Text]
65. Lennon VA, Wingerchuk DM, Kryzer TJ, et al. A serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis. Lancet. 2004 Dec 11-17;364(9451):2106-12.[Abstract]
66. Lindenbaum J, Savage DG, Stabler SP, et al. Diagnosis of cobalamin deficiency: II. Relative sensitivities of serum cobalamin, methylmalonic acid, and total homocysteine concentrations. Am J Hematol. 1990 Jun;34(2):99-107.[Abstract]
67. Hart G. Syphilis tests in diagnostic and therapeutic decision making. Ann Intern Med. 1986 Mar;104(3):368-76.[Abstract]
68. Marra CM, Tantalo LC, Maxwell CL, et al. Alternative cerebrospinal fluid tests to diagnose neurosyphilis in HIV-infected individuals. Neurology. 2004 Jul 13;63(1):85-8.[Abstract]
69. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan 15;64(2):111-5.[Abstract][Full Text]
70. Geldmacher H, Taube C, Kroeger C, et al. Assessment of lymph node tuberculosis in northern Germany: a clinical review. Chest. 2002 Apr;121(4):1177-82.[Abstract][Full Text]
71. Weir MR, Thornton GF. Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature. Am J Med. 1985 Oct;79(4):467-78.[Abstract]
72. Baydur A. The spectrum of extrapulmonary tuberculosis. West J Med. 1977 Apr;126(4):253-62.[Abstract]
73. Nataraj G, Kurup S, Pandit A, et al. Correlation of fine needle aspiration cytology, smear and culture in tuberculous lymphadenitis: a prospective study. J Postgrad Med. 2002;48(2):113-6.[Abstract]
74. World Health Organization. WHO consolidated guidelines on tuberculosis: module 3: diagnosis. 2025 [internet publication].[Full Text]
75. Centers for Disease Control and Prevention (CDC). Updated guidelines for the use of nucleic acid amplification tests in the diagnosis of tuberculosis. MMWR Morb Mortal Wkly Rep. 2009 Jan 16;58(1):7-10.[Abstract][Full Text]
76. Bjerrum S, Schiller I, Dendukuri N, et al. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis in people living with HIV. Cochrane Database Syst Rev. 2019 Oct 21;10(10):CD011420.[Abstract][Full Text]
77. Puccioni-Sohler M, Rios M, Carvalho SM, et al. Diagnosis of HAM/TSP based on CSF proviral HTLV-I DNA and HTLV-I antibody index. Neurology. 2001 Aug 28;57(4):725-7.[Abstract]
