Dizziness Decoded: New Rules, Algorithms and Genetics Reshape Vestibular Medicine

Vertigo and dizziness send millions of people to doctors every year, and they remain among the most common reasons patients visit a primary care clinic or an emergency department. Yet for decades the evaluation of the dizzy patient was notoriously inconsistent, with dangerous strokes missed and benign conditions over-treated. A comprehensive review published in the Journal of Neurology by Alexander Tarnutzer, Michael Strupp and Louisa Lehner now pulls together the developments of the past three years in neuro-otology and neuro-ophthalmology, and the picture that emerges is one of rapid, sometimes surprising progress: new diagnostic criteria, validated bedside algorithms, machine learning tools, renamed diseases and the first genuinely promising drug trials in conditions long considered untreatable.

The review is organized around how patients actually present: acute, episodic, or persistent symptoms. In the acute category, the authors highlight a newly characterized entity called the acute imbalance syndrome, or AIS, defined as an acute vestibular syndrome without nystagmus. Among emergency department consultations for vertigo or dizziness, roughly ten percent meet criteria for the acute vestibular syndrome, and about one fifth of those patients ultimately turn out to have suffered a stroke. Crucially, nearly half of central cases present as AIS rather than the classic nystagmus-associated form. Lesion-symptom mapping in stroke patients shows that AIS lesions cluster in the anterior cerebellar lobe, disrupting networks for posture and gait control, while the classic syndrome with nystagmus involves the posterior cerebellar and flocculonodular lobes and their vestibulo-ocular reflex circuits. This anatomical split means clinicians must choose their bedside tests carefully: when no nystagmus is present, algorithms such as STANDING are the appropriate choice.

For acute unilateral vestibulopathy, often called vestibular neuritis, the epidemiological picture has shifted. A Japanese nationwide survey estimated the annual incidence at about 7.1 per 100,000, double the figure recorded in 1993, likely reflecting better recognition of dizziness as the presenting symptom. About twenty percent of patients experience prodromal dizziness hours to days before the full syndrome, and involvement of both divisions of the vestibular nerve predicts more intense, longer-lasting symptoms and a higher risk of secondary functional dizziness. Delayed post-contrast 3D-FLAIR MRI now visualizes inflammatory enhancement of the labyrinth in roughly half of patients, offering an objective window into the disease process. The video head-impulse test remains the first instrumental examination, with a vestibulo-ocular reflex gain below 0.7 on the affected side serving as the recommended cut-off to separate peripheral from central lesions.

Treatment of vestibular neuritis still rests on three pillars, but each has been refined. Symptomatic drugs such as dimenhydrinate should be limited to one to three days. Steroids remain guideline-endorsed, although a recent placebo-controlled trial showed no effect on peripheral vestibular recovery, a result the authors attribute to a total steroid dose only a quarter of that used in the landmark 2004 randomized trial, leaving the question genuinely open. Physiotherapy has emerged as the strongest evidence-based intervention: a recent randomized trial found that an individualized program including rapid head rotations, performed three times daily for eight weeks, was probably the most effective approach, while isolated eye movements in a static head position show no benefit. In animal work, betahistine enhanced central compensation in a dose-dependent fashion, an effect amplified by combination with the MAO-B inhibitor selegiline, setting the stage for human trials.

Perhaps the most consequential advances concern the emergency department, where the stakes are highest. Vertical or torsional spontaneous nystagmus, though present in only about fifteen percent of acute vestibular syndrome patients, is highly predictive of a central cause, with specificity approaching 98 percent. Adding new-onset hearing loss to the HINTS battery mainly helps detect strokes of the anterior inferior cerebellar artery, raising stroke sensitivity by nearly eighteen percentage points in that subgroup. The four-step STANDING algorithm has now been validated repeatedly: after a single training session, interns achieved a sensitivity of about 85 percent and specificity of about 90 percent for dangerous central causes, and in a multicenter Italian study of isolated acute vertigo, trained emergency physicians using STANDING substantially outperformed standard care, while also reducing unnecessary head CT scans. A meta-analysis further showed that moderately trained non-specialists reach sensitivity comparable to subspecialists, though with somewhat lower specificity, and that as little as six hours of structured training suffices for successful implementation.

Technology is now entering the acute workflow. Machine learning models applied to video head-impulse data from all six semicircular canals distinguished stroke from vestibular neuritis with an accuracy of 87.8 percent, matching blinded expert clinicians and clearly beating simple gain cut-offs. A meta-analysis of horizontal canal data across 905 patients reported sensitivity of 85 percent and specificity of 84 percent for stroke detection, with a negative likelihood ratio useful for ruling out the disease. A separate retrospective model combining saccade gains, pursuit asymmetries, age and hypertension differentiated posterior circulation stroke from peripheral disease with sensitivity and specificity above 82 percent. The authors caution, however, that radiographic conjugate gaze deviation on CT or MRI cannot by itself separate peripheral from central causes and does not replace bedside examination.

In episodic vertigo, the review champions a provocative renaming: benign paroxysmal positional vertigo should become peripheral paroxysmal positional vertigo, because the condition is often not benign at all. Delayed diagnoses, atypical presentations in the elderly, high recurrence rates, fear of falling and residual dizziness in up to seventy percent of successfully treated patients all argue against the label. When the supine roll test is performed correctly, with the head raised twenty-five degrees and the whole body turned, horizontal canal variants account for nearly forty percent of cases, far more than previously appreciated. On the therapy side, the Semont Plus maneuver, which moves the head at least 150 degrees to the affected side based on biophysical modeling, halved the mean time to symptom freedom compared with the classic Semont maneuver and outperformed the Epley maneuver in randomized trials. For Menière’s disease, six 2023 Cochrane analyses rated the evidence for most established treatments as low or very low, but a phase 1 study showed that combining betahistine with selegiline increases the drug’s bioavailability a hundredfold, and a properly powered placebo-controlled trial is planned.

Vestibular migraine, the most common cause of recurrent spontaneous vertigo, is being reconceived as a broad spectrum rather than a narrow diagnosis. In a 2025 cross-sectional study of 2,801 newly diagnosed migraine patients, 68.4 percent reported vestibular symptoms, yet only 15.2 percent met formal diagnostic criteria. Therapeutically, the first adequately designed acute trial found rizatriptan ineffective against vertigo, but the INVESTMENT study, the first placebo-controlled trial of a CGRP monoclonal antibody in vestibular migraine, showed that galcanezumab improved disease-specific handicap and reduced dizzy days without serious adverse events, and a 2025 network meta-analysis ranked it as the current best preventive option. Meanwhile, delayed gadolinium-enhanced MRI revealed that endolymphatic hydrops occurs in vestibular migraine too, though typically bilateral, low-grade and vestibular-predominant, helping distinguish it from the pronounced, lateralized hydrops of Menière’s disease.

Genetics has transformed the understanding of chronic vestibular disorders. In bilateral vestibulopathy, biallelic RFC1 repeat expansions were found in eight percent of isolated cases, making RFC1 the most common monogenic cause, while FGF14 GAA expansions define the new spinocerebellar ataxia 27b. Quantitative vestibulo-ocular reflex testing now separates these entities at the bedside: a horizontal gain cut-off of 0.50 distinguished RFC1-related ataxia from SCA 27b with 91 percent specificity, and vHIT gains correlate with repeat size and disease duration, offering a progression biomarker. In so-called idiopathic downbeat nystagmus, FGF14 expansions were detected in roughly half of patients, and carriers showed an 80 percent response rate to 4-aminopyridine, compared with under five percent in RFC1 carriers whose disease involves neurodegeneration rather than reduced Purkinje cell excitability, a striking closure of the loop between genotype, mechanism and therapy.

The review closes with candid gaps. Functional dizziness, including persistent postural-perceptual dizziness, develops in roughly one in four patients after acute or episodic vestibular disorders, and new work on gaze behavior, maladaptive multisensory integration and illness-related cognitive appraisals is clarifying its mechanisms. Yet acute vestibular migraine episodes still evade emergency algorithms, evidence for thrombolysis and thrombectomy in posterior circulation stroke presenting as dizziness remains too thin for firm recommendations, and the authors emphasize that the field’s greatest unmet need is not new ideas but rigorous, placebo-controlled clinical trials with meaningful endpoints, together with systematic training so that the remarkable diagnostic knowledge of the last three years actually reaches the bedside.

Subject of Research: Recent advances in the diagnosis and treatment of vestibular and ocular motor disorders, including acute vestibular syndrome, positional vertigo, vestibular migraine and bilateral vestibulopathy

Article Title: An update on neuro-otology and neuro-ophthalmology – focusing on new developments in the last three years

Article References: Tarnutzer, A. A., Strupp, M. L., & Lehner, L. (2026). An update on neuro-otology and neuro-ophthalmology – focusing on new developments in the last three years. Journal of Neurology, 273(11), Article 657. https://doi.org/10.1007/s00415-026-14153-w

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14153-w

Keywords: vertigo, dizziness, vestibular disorders, stroke, HINTS, STANDING algorithm, vestibular migraine, Meniere's disease, bilateral vestibulopathy, vestibular neuritis, video head-impulse test, machine learning