Vestibular Evaluation: What to Expect and When You Need One

A vestibular evaluation is a set of painless, noninvasive tests that measure how well your inner ear and brain work together to keep you balanced. You may need one if you experience dizziness, vertigo, unsteadiness, recurring falls, or a spinning sensation triggered by head or body movements. The appointment typically runs at least 90 minutes to two hours and gives your care team the information needed to identify the cause of your symptoms and guide the next step in treatment.

What is a vestibular evaluation?

Your sense of balance relies on three systems working together: your inner ear (the vestibular system), your eyes, and your body’s position sensors in your joints and muscles. When all three agree on where your body is in space, you feel steady. When the signals disagree, you feel dizzy, unsteady, or as if the room is moving. A vestibular evaluation focuses on the inner ear side of that equation, measuring how the tiny balance organs inside your ears are functioning and how well your brain is interpreting the signals they send.

The evaluation is a battery of tests, not a single procedure. Your audiologist will typically perform several different assessments during one appointment, each designed to examine a specific part of the system. Some tests measure eye movements. Others check how your body responds when you change positions. A few measure muscle responses to sound. Together, the results give a detailed picture of where in the balance pathway the problem may be coming from, and whether it’s likely peripheral (in the inner ear or vestibular nerve) or central (in the brain’s processing).

It helps to know upfront what the evaluation will and will not do. At Northwest Speech and Hearing Center in Arlington Heights, your audiologist performs the dizziness and balance assessment. If the results point toward a condition that requires physical therapy or medical treatment, we coordinate with your physician or refer you to a physical therapist who specializes in vestibular rehabilitation. The evaluation itself is diagnostic. It tells you and your providers what’s happening so that treatment decisions can be made from a place of information rather than guesswork.

If you’re unsure whether what you’re feeling is actually a vestibular issue, our resource on dizziness vs. vertigo walks through how the two sensations differ and what each one usually means.

When should you consider a vestibular evaluation?

Most people wait too long. Occasional lightheadedness after standing up quickly or a brief spell of dizziness from dehydration usually doesn’t warrant a formal evaluation. But when symptoms become persistent, recurrent, or disruptive to daily life, that’s when testing becomes valuable.

Consider scheduling an evaluation if you experience any of the following:

• A spinning sensation (true vertigo) triggered by rolling over in bed, bending, or looking up
• Unsteadiness or a feeling that you might fall, especially when walking on uneven surfaces or in dim light
• Dizziness that lasts more than a few minutes or keeps coming back over weeks or months
• Episodes of fullness, pressure, or ringing in one ear combined with dizziness or hearing changes
• A history of falls, especially in the past year
• Nausea or visual blurring that accompanies head movements
• Symptoms that started after a head injury, ear infection, or viral illness
• Difficulty focusing your eyes on a target while your head is moving (sometimes called oscillopsia)

Pay attention to patterns, not just symptoms in isolation. Brief spinning episodes triggered specifically by changes in head position (bending over, rolling over in bed, looking up to reach a shelf) point to BPPV. Longer episodes of vertigo lasting 20 minutes to several hours, accompanied by hearing changes and ear fullness, can mean other diagnoses. Dizziness with headache, light sensitivity, or a personal or family history of migraine points to vestibular migraine. Your audiologist uses these patterns to choose which tests to emphasize during the evaluation.

Some symptoms warrant immediate medical attention rather than a scheduled evaluation. If dizziness appears suddenly alongside chest pain, difficulty speaking, weakness or numbness on one side of the body, severe headache, or vision changes, seek emergency care. Those can be signs of a stroke or other urgent condition, not a peripheral vestibular disorder.

Falls are another important reason to pursue testing, particularly for older adults. CDC data on older adult falls shows that more than one in three adults age 65 and older fall each year, and fewer than half tell their doctor. Balance screening through a vestibular evaluation can help identify inner ear contributors to fall risk so that targeted interventions can be put in place.

Who performs vestibular evaluations?

Vestibular evaluations are performed by audiologists who have specialized training in balance disorders. Not every audiologist does this testing. The equipment is specific, the interpretation takes experience, and the tests build on each other in ways that require clinical judgment.

At Northwest Speech and Hearing Center, your evaluation is in the hands of two audiologists who have each dedicated their careers to understanding dizziness and balance disorders. Dr. Kimberley Franczyk, AuD, is a Doctor of Audiology with a specialized focus on dizziness and balance who evaluates patients of all ages. She built much of her expertise at major medical centers, including Rush University Medical Center, and listens closely to patients’ concerns so she can tailor her testing approach. She’s skilled at differentiating dizziness caused by inner ear dysfunction from dizziness that originates in the cervical spine or central nervous system, which helps ensure your care plan is focused on the right cause from the start.

Dr. Michelle Petrak, PhD, brings more than 30 years of vestibular research experience and has helped develop diagnostic tools used by clinicians around the world. In 2024, she was inducted into the Bárány Society, the international organization that sets diagnostic standards for vestibular disorders, recognizing her lifetime of contributions to how balance disorders are diagnosed and treated. Consensus criteria documents published by Bárány Society are what clinicians and researchers use worldwide to define conditions like BPPV, Ménière’s disease, vestibular migraine, and bilateral vestibulopathy, so an evaluation grounded in this level of expertise means your results are interpreted using the same standards used in leading research centers.

Vestibular care is collaborative by nature. Your audiologist often works alongside your primary care physician, an ear-nose-and-throat (ENT) specialist or neurologist, and sometimes a physical therapist who specializes in vestibular rehabilitation. The evaluation is a shared starting point for everyone involved in your care.

What happens during a vestibular evaluation?

Living with dizziness, vertigo, or imbalance is unsettling on its own, and not knowing the cause only adds to that. Your audiologist’s job is to listen closely to what you’re experiencing and help you get real answers, not just a printout of numbers.

Intake and medical history

Your appointment starts with a thorough conversation. Your audiologist will ask about when your symptoms began, what they feel like, what triggers them, how long they last, and what makes them better or worse. Questions about your medical history, medications, recent illnesses, head injuries, and hearing changes help shape which tests make the most sense for you. Because of the lengthy case history, we ask that this history is filled out and returned prior to your appointment.

This part is more than paperwork. A careful history often narrows the diagnostic possibilities before any equipment is turned on.

Balance and vestibular testing

No two evaluations look exactly alike. Depending on what you’re experiencing, your audiologist may draw from a full battery of tests, some of which go well beyond what a standard clinic typically offers, so that nothing about your balance system gets overlooked. Here’s a closer look at what that can include:

Standard VNG

Videonystagmography, or VNG, is usually the starting point. You’ll wear lightweight goggles with a small infrared camera that records your eye movements while you follow visual targets and move into different positions. Because your inner ear and eyes are wired together through a reflex called the vestibulo-ocular reflex, those eye movements tell your audiologist a lot about whether your inner ear is sending the right signals and whether your brain is interpreting them correctly.

Video Head Impulse Test (vHIT) 6-Canal Assessment

vHIT uses similar goggles, but with high-speed cameras that track your eyes while your head is moved gently and briefly in different directions. Standard VNG mainly evaluates two of your six semicircular canals, while vHIT can assess all six independently, which means it can catch subtle or isolated canal problems that might otherwise be missed.

Advanced Dix-Hallpike with Torsional Analysis

The Dix-Hallpike maneuver is the standard way to check for BPPV. Your audiologist guides your head and body into specific positions while watching for the telltale eye movement pattern that signals displaced crystals in a semicircular canal. Adding high-resolution torsional analysis sharpens that picture further, which is especially useful for cases that are atypical, recurring, or haven’t responded to treatment.

Lateral Head Roll Test (for Horizontal Canal BPPV)

This test has you roll your head side to side while lying down, to check specifically for BPPV in the horizontal canal, a variant that the standard Dix-Hallpike position can sometimes miss. Pinpointing the right canal matters, since the repositioning maneuver used to treat BPPV depends on which canal the crystals are in.

Active Head Rotation (AHR)

AHR checks how your inner ear responds at the faster head speeds you actually use in daily life, rather than the slower movements used in some other tests. While wearing tracking goggles, you’ll rotate your head back and forth at a few different speeds, which can surface peripheral vestibular deficits that don’t always show up on slower-paced testing.

cVEMP (Cervical Vestibular Evoked Myogenic Potentials)

cVEMP measures how your saccule, one of the otolith organs that sense gravity and motion, responds to sound. Small electrodes on your neck pick up tiny muscle responses while you listen to clicking or tone sounds through headphones, which gives your audiologist a window into a pathway the other tests don’t reach.

oVEMP (Ocular Vestibular Evoked Myogenic Potentials)

oVEMP works on the same principle but with electrodes placed under your eyes, targeting the utricle rather than the saccule. Together, cVEMP and oVEMP give your audiologist a fuller picture of how your otolith organs are functioning, and findings from either can point toward conditions such as superior canal dehiscence, Ménière’s disease, or certain types of vestibular neuritis.

Electrocochleography (ECoG)

ECoG measures electrical activity inside your inner ear to check for fluid-pressure abnormalities. It’s particularly useful when Ménière’s disease or another fluid-related inner ear condition is suspected.

For a complete list of advanced vestibular and balance testing, please check out our balance and vestibular testing page.

Preparing for your appointment

Preparation is straightforward but matters, because some substances can interfere with the testing.

For 48 hours before your appointment, your audiologist will typically ask you to avoid:

• Alcohol
• Caffeine (coffee, tea, energy drinks, sodas)
• Certain over-the-counter medications that suppress vestibular symptoms, such as meclizine or antihistamines that cause drowsiness
• Sedating or sleep medications including narcotics.

Continue taking any prescribed medications for chronic conditions (blood pressure, heart medications, anti-seizure medications) unless your audiologist or physician instructs you otherwise. If you’re unsure whether a medication affects the test, call ahead.

On the day of the evaluation:

• Skip eye makeup and mascara. The VNG goggles rest against your cheekbones and need a clear view of your eyes.
• Eat a light meal beforehand. Some test components can cause brief dizziness, and an empty stomach can make that feel worse.
• Wear comfortable clothing. You’ll be sitting, lying down, and moving through different positions.
• Bring a driver if possible. Some patients feel unsteady for a short time after testing.

Bring a list of your medications, all your paperwork that was emailed to you when you scheduled the appointment, and any imaging or records from prior visits with other providers.

Understanding your results

Your audiologist will review the results with you, often during the same appointment. Findings are typically described in two broad categories: peripheral (the problem is in the inner ear or vestibular nerve) or central (the signal coming from the ear is fine but the brain is processing it abnormally). MedlinePlus offers a plain-language overview of this distinction.

Common conditions identified through vestibular evaluation include:

• BPPV, the most frequent cause of positional vertigo, caused by tiny crystals displaced into one of the semicircular canals. Highly treatable, often within just one or two sessions of simple repositioning.
• Vestibular neuritis or labyrinthitis, typically following a viral illness. Sudden, severe vertigo that lasts for days, often without hearing changes in neuritis and with hearing changes in labyrinthitis.
• Ménière’s disease, characterized by recurring episodes of vertigo with fluctuating hearing loss, tinnitus, and a feeling of fullness in one ear. The National Institute on Deafness and Other Communication Disorders estimates about 615,000 people in the United States have Ménière’s disease, with roughly 45,500 new cases diagnosed each year.
• Cervicogenic (neck-related) dizziness, often tied to whiplash, neck arthritis, or longstanding poor posture, with dizziness that tends to flare alongside neck pain or with neck movement.
• POTS (postural orthostatic tachycardia syndrome), a condition affecting how your body regulates blood flow when you move from lying or sitting to standing, often causing lightheadedness, a racing heart, and fatigue alongside dizziness.
• PPPD (persistent postural-perceptual dizziness), a persistent swaying or rocking sensation, rather than true spinning, that tends to worsen when you’re upright or taking in a lot of visual input, and that often develops after an earlier episode of vertigo, a vestibular migraine, or a concussion.
• Bilateral vestibulopathy, a loss of function in both inner ears causing unsteadiness, especially in the dark or on uneven ground.
• Superior canal dehiscence, a rare structural condition in which sound or pressure triggers dizziness.
• Acoustic neuroma or other growths on the vestibular nerve, which would prompt referral for imaging.
• Presbyvestibulopathy, an age-related decline in vestibular function that can contribute to falls.

A normal evaluation is also informative. If your inner ear is working well, your care team can focus on other potential causes, such as blood pressure changes, medication side effects, anxiety disorders, cervicogenic (neck-related) dizziness, or central nervous system conditions. Some patients find this reassuring. Others feel frustrated because they still don’t have an answer. In either case, a normal result is a useful data point that narrows the search.

Your audiologist will explain what the test numbers mean and how they connect to your symptoms. If results are ambiguous, repeat testing or additional imaging may be recommended.

Next steps after your evaluation

This is where the evaluation hands off to treatment. Your audiologist does not perform vestibular rehabilitation or prescribe medications. What happens next depends on what the testing showed.

BPPV is highly treatable, and many patients experience significant relief in just one or two sessions of simple repositioning. If the findings point toward Ménière’s disease, you’ll typically be coordinated with your primary care physician or an ENT for medical management, which can include dietary changes, diuretics, and in some cases more advanced interventions.

If the problem is a weakness in one inner ear or both, a vestibular physical therapist can guide you through exercises that help your brain compensate. This is called vestibular rehabilitation therapy, and it’s highly effective for many patients. It works by training the brain to recalibrate how it interprets signals from the inner ear, similar to how the brain adapts when you wear a new pair of eyeglasses. Your audiologist’s report gives the physical therapist specific information about where the deficit is, which allows for a targeted rehabilitation plan rather than a generic one.

We coordinate with physicians and therapists across the Chicagoland area so that your results, recommendations, and treatment plan are communicated clearly to everyone involved in your care. You won’t be left to figure out the next steps alone. For more guidance on whether an audiologist is the right starting point for your symptoms, see our article on when to see an audiologist for dizziness or balance issues.

Frequently asked questions

How long does a vestibular evaluation take?

Most evaluations run between 90 and 120 minutes, depending on which tests are included. A full battery with VNG, vHIT, and VEMP, and other tests can take over two hours.

Is the testing painful or dangerous?

No. The tests are noninvasive and don’t involve needles, radiation, or medications. Some components can briefly trigger your symptoms (dizziness, a short spinning sensation), which is part of how the tests work. Discomfort typically passes within a few minutes.

Will my insurance cover the evaluation?

Coverage varies by insurance plan and by the specific tests included. Most medical insurance plans covers some of the vestibular testing when it’s medically necessary. Some of our more advanced, specialized tests are newer to the field and don’t yet have standard insurance billing codes, so they’re offered on a transparent self-pay basis. We recommend checking with your insurance provider or contacting our office so we can help verify benefits before your appointment.

Can my primary care doctor order a vestibular evaluation?

In many cases, your primary care physician or ENT will refer you for testing. You can also self-refer in many cases. If you’re unsure whether your insurance requires a referral, call ahead so we can help you sort that out.

Will I be able to drive after the appointment?

Many patients feel fine afterward, but some feel briefly unsteady, especially after positional testing components. If you’re unsure how you’ll respond, we recommend arranging for someone to drive you home if possible.

What if my results are normal but I still feel dizzy?

A normal vestibular evaluation is useful information, not a dead end. It tells your care team to look beyond the inner ear for the source of your symptoms. Blood pressure, medication effects, migraine, anxiety, and cervical spine issues are all possibilities that your physician can help investigate.

This article is for informational purposes and not a substitute for medical advice. If you’re experiencing dizziness, vertigo, or balance concerns, please schedule a consultation to discuss your specific situation with a qualified audiologist.