BALANCE TESTS

VESTIBULAR (BALANCE SYSTEM) ASSESSMENT TESTS

 

In Brief

• Balance tests objectively assess how the balance organ of the inner ear (the vestibular system) and its connections with the brain are working, by measuring eye movements and muscle responses.

• They help to tell whether dizziness comes from the inner ear (peripheral) or from the brain (central), and to identify which ear and which part of the balance organ is affected.

• None of the tests is painful or invasive. Some may cause brief dizziness; this is expected and temporary.

• Not everyone needs every test. Which tests are performed is decided after the history and examination.

 

Why Are Tests Needed?

The cause of dizziness can usually be understood from a detailed history and examination. In some cases, however, measurable data are needed to clarify the diagnosis, compare the two ears, or follow the stage of the disease or the response to treatment. Because the balance organ cannot be imaged directly, the eye movements that reflect its function (the vestibulo-ocular reflex) and the responses of the neck and eye muscles are recorded. Test results are never interpreted on their own, but together with the examination findings and, when needed, hearing tests.

 

Main Tests

1. Videonystagmography (VNG)

Light goggles containing an infrared camera are worn and the eye movements are recorded. The test includes involuntary eye movements (nystagmus), gaze-evoked nystagmus, rapid eye movements (saccades), smooth pursuit and following moving patterns (optokinetic testing). These parts are particularly important for identifying balance disorders that originate in the brain (central). Positional and caloric tests are also usually performed with the VNG goggles.

2. Positional Tests (Dix-Hallpike and Supine Roll Test)

The patient is moved into specific head and body positions while the eye movements are observed. This is the key test for diagnosing positional vertigo (BPPV, “ear crystals”); it shows which ear and which semicircular canal is involved. Dizziness lasting from a few seconds to a minute may be felt during the test. Once the diagnosis is made, the treatment manoeuvre can often be performed in the same session.

3. Caloric Test

Warm and cool air or water is delivered in turn into the ear canal to stimulate the balance organ of each inner ear separately, and the resulting eye movements are measured. Because it shows the difference between the two ears, it is valuable for identifying one-sided loss of balance function (for example vestibular neuritis or Ménière’s disease). A spinning sensation lasting about 1–2 minutes and settling on its own is expected during stimulation. If there is a hole in the eardrum, air is used instead of water.

4. Video Head Impulse Test (vHIT)

Light goggles are worn; while the patient looks at a target in front of them, the doctor turns the head with small, quick movements to the right, to the left and diagonally. The test measures whether the eyes can keep their gaze steady during these movements. It can assess each of the six semicircular canals of the inner ear separately, is short (about 10–15 minutes) and well tolerated. It is commonly used in vestibular neuritis, loss of balance function on both sides (bilateral vestibulopathy) and Ménière’s disease. A neck hernia, a recent neck injury or severe neck pain should be mentioned before the test.

5. Vestibular Evoked Myogenic Potentials (VEMP)

Short sounds are played through headphones, and the reflex response of the balance organ to these sounds is recorded with small electrodes attached to the skin.

• Cervical VEMP (cVEMP): Electrodes are placed on a neck muscle and the patient turns the head slightly to one side. It assesses the saccule of the inner ear and the inferior vestibular nerve.

• Ocular VEMP (oVEMP): Electrodes are placed below the eyes and the patient looks up. It assesses the utricle and the superior vestibular nerve.

It complements the other tests because it examines the otolith organs (sensors of gravity and linear movement), which the tests of the semicircular canals cannot see. It is used in Ménière’s disease, superior semicircular canal dehiscence, and in identifying which nerve branch is affected in vestibular neuritis.

 

Complementary Tests

If dizziness is accompanied by hearing loss, ringing in the ear or a feeling of fullness in the ear, hearing tests (audiometry, tympanometry) are performed together with the balance tests. When considered necessary, magnetic resonance imaging (MRI) or a neurological assessment may also be planned.

 

Summary of Tests

• VNG (oculomotor tests): Eye movements, disorders originating in the brain · 15–20 min* · Does not cause dizziness.

• Positional tests: BPPV (“ear crystals”) · 5–10 min* · May cause brief dizziness.

• Caloric test: The balance organ of each ear separately (horizontal canal) · 20–30 min* · Brief dizziness is expected.

• vHIT: Each of the six semicircular canals · 10–15 min* · Does not cause dizziness.

• VEMP: Saccule, utricle and the vestibular nerve branches · 20–30 min* · Does not cause dizziness.

*Durations are approximate and depend on the number of tests performed.

 

Before Your Test

• Medicines: Some medicines used for dizziness, nausea, allergy and sleep (such as sedatives and some antihistamines) can affect the test results. Whether these medicines should be stopped before the test, and how long before, must always be decided by your doctor. Do not stop medicines you take regularly, such as those for the heart, blood pressure, diabetes, epilepsy or psychiatric conditions, on your own.

• Alcohol: Avoiding alcohol for 48 hours before the test is recommended.

• Eye make-up: Mascara and eyeliner can interfere with the camera recording and should not be worn on the day of the test.

• Eating: A light meal before the test is enough; a heavy meal may increase nausea.

• Companion: Because brief light-headedness may follow the caloric and positional tests, it is recommended to come with a companion if possible and not to drive immediately after the test.

Please tell us before the test if you wear glasses or contact lenses, have a neck problem, or know that you have a hole in your eardrum.

 

Frequently Asked Questions

Are the tests painful? No. None of them involves needles or painful procedures. A brief spinning sensation may occur during the caloric and positional tests.

When are the results available? Most measurements are obtained during the test; the results are evaluated together with the examination findings and shared on the same day or at the follow-up visit.

If the tests are normal, does that mean I have no dizziness problem? No. In some conditions (for example vestibular migraine, PPPD, or Ménière’s disease between attacks) the tests may be normal. In that case the diagnosis rests mainly on the history and the diagnostic criteria.

 

Detailed information for physicians (vestibology.com): Head-movement and head-still tests · VEMP · Nystagmus atlas · Bedside examination · Audiological tests

Last updated: November 2026 · Editor: Assoc. Prof. Mehmet Sürmeli · Source: Bárány Society classification of vestibular disorders and current vestibular testing guidelines. This page is for general information and does not replace examination and diagnosis.