The study, led by Huseyin Nezih Ozdemir, Iryna Klopotovska and Diego Kaski of the SENSE Research Unit in UCL’s Department of Clinical and Movement Neurosciences, was conducted at the National Hospital for Neurology and Neurosurgery in London between April 2025 and April 2026. Consecutive patients aged 18 and over arriving at the dizziness clinic underwent a structured ten-question interview before their clinical consultation. Crucially, the interviewer recorded answers about symptom timing, triggers, avoidance behaviours and behavioural responses before any diagnosis had been established. The final diagnoses were then made independently by a vestibular neurologist who was blinded to the interview responses, using established criteria from the Bárány Society and the International Classification of Headache Disorders. This design ensured that the behavioural data could not be contaminated by knowledge of the diagnosis.

The cohort of 109 patients had a mean age of 55.3 years, and 71.5 percent were female. Thirty-three patients were diagnosed with vestibular migraine, thirty-three with persistent postural-perceptual dizziness, fourteen with benign paroxysmal positional vertigo and fifteen with orthostatic dizziness. Smaller groups included patients with central structural disorders such as posterior circulation stroke and other peripheral vestibular conditions including bilateral vestibular loss. When the researchers applied logistic regression to the interview data, four clear behavioural profiles emerged, each mapping closely onto the known biology of the underlying disorder.

The strongest single predictor belonged to vestibular migraine. Patients who reported that reading while travelling as a passenger in a vehicle brought on their dizziness were more than twenty times more likely to have vestibular migraine than any other diagnosis, with an odds ratio of 20.99. This finding fits with the idea that vestibular migraine reflects a heightened vulnerability to sensory conflict, the discordance between visual motion signals and vestibular input that occurs when the eyes track a page while the inner ear registers the movement of a car. It also builds on earlier work from the same group showing that motion sickness while reading in a moving car is highly predictive of the condition. For patients with persistent postural-perceptual dizziness, visually stimulating environments such as crowded, busy or visually complex settings were the strongest precipitating factor, carrying an odds ratio of 12.45, consistent with the disorder’s characteristic over-reliance on visual cues for spatial orientation.

The two remaining diagnoses produced equally distinctive patterns. For benign paroxysmal positional vertigo, head movements and positional changes were the dominant trigger, with an odds ratio of 11.51, exactly what would be expected from the abnormal movement of displaced calcium carbonate crystals, or otoconia, within the semicircular canals. Patients with orthostatic dizziness, by contrast, pointed to standing up quickly as their principal trigger, reflecting the transient drop in cerebral blood flow that occurs during orthostatic stress. In each case, the reported precipitant was not an arbitrary preference but a direct behavioural echo of the underlying mechanism: sensory conflict in vestibular migraine, visual dependence in persistent postural-perceptual dizziness, otoconial displacement in positional vertigo and cerebral hypoperfusion in orthostatic dizziness.

Avoidance behaviours proved just as diagnostic as triggers. Patients with vestibular migraine disproportionately avoided bright or noisy environments and sought refuge by resting in dark, quiet rooms, mirroring the visual and auditory hypersensitivity that characterises migraine more broadly. Those with persistent postural-perceptual dizziness avoided visually busy places such as supermarkets, crowded streets or scrolling screens, and notably reported trying to maintain their activity despite the symptoms, an effort to push through the persistent, physically non-disabling dizziness that defines the condition. Patients with benign paroxysmal positional vertigo reported deliberately avoiding quick head movements and staying still during attacks, an understandable strategy to prevent the violent, brief episodes of rotational vertigo that position changes provoke. Orthostatic dizziness patients avoided sudden standing and tended to sit or lie down slowly, a sensible countermeasure against orthostatic intolerance, although this particular association did not reach statistical significance, likely because of the smaller size of that subgroup.

Temporal patterns added a further layer of discrimination. Episodic dizziness was significantly associated with vestibular migraine, while patients with persistent postural-perceptual dizziness were far more likely to report continuous dizziness lasting days or longer, in keeping with the chronic nature of that disorder. Patients with benign paroxysmal positional vertigo characteristically reported brief episodes lasting seconds to minutes, matching its paroxysmal presentation. Although patients with positional vertigo and orthostatic dizziness tended to describe dizziness that comes and goes, these associations did not reach statistical significance, a limitation the authors attribute to the relatively small numbers in those diagnostic groups.

The clinical implications of the work are considerable. Because neuroimaging has limited utility in most cases of dizziness and definitive tests are lacking for many vestibular syndromes, diagnosis rests heavily on history taking, and patients’ descriptions of symptom quality are notoriously imprecise. Structured questions about avoidance and coping could capture dimensions of the patient’s experience that conventional symptom questions miss. Asking simply whether a patient avoids supermarkets, refrains from turning their head quickly, or retreats to a dark room when dizzy may sharpen diagnostic accuracy, shorten the long delays many patients experience before correct treatment, and potentially prevent progression to chronic dizziness. Beyond diagnosis, recognising these behaviours may help clinicians understand how the disorders impair daily and occupational functioning, since triggers such as bright environments or awkward head positions have been shown to interfere with work tasks and contribute to reduced productivity and absenteeism.

Perhaps the most intriguing aspect of the findings is that patients developed these behavioural signatures without any formal knowledge of disease mechanisms. The researchers argue that such adaptations arise intuitively through repeated symptom experience, which is precisely what makes them informative: they represent the body’s own experiment on the disorder, conducted over months or years. The behaviours therefore function as natural biomarkers, reflecting pathophysiology rather than clinical teaching. The authors also caution that avoidance behaviours can themselves contribute to disability, and identifying them may open the door to rehabilitation strategies that prevent deconditioning and fear-driven withdrawal from activity.

The study is not without limitations. The structured interview was not a validated instrument, several diagnostic subgroups were small, limiting statistical power for some response categories, and the single-centre design in a specialised London clinic may constrain generalisability. Larger cohorts will be needed to confirm the diagnostic value of these behavioural markers and to quantify their impact on patients’ functioning. Even so, the message is clear and potentially transformative for routine practice: when a patient says they feel dizzy, the clinician should ask not only what it feels like and when it happens, but what the patient does about it. The answers, this research suggests, may point directly to the diagnosis hiding behind one of medicine’s most vague and common complaints.

Subject of Research: Behavioural signatures as diagnostic clues in common vestibular disorders causing dizziness

Article Title: What patients do when they feel dizzy: behavioural signatures reveal diagnostic clues in common vestibular disorders

Article References: Ozdemir, H. N., Klopotovska, I., & Kaski, D. (2026). What patients do when they feel dizzy: behavioural signatures reveal diagnostic clues in common vestibular disorders. Journal of Neurology, 273(10), Article 587. https://doi.org/10.1007/s00415-026-14133-0

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14133-0

Keywords: dizziness, vestibular disorders, vestibular migraine, PPPD, BPPV, orthostatic dizziness, avoidance behaviour, coping strategies, behavioural adaptation, diagnosis, vertigo, neurology

The vestibular system relies on signals from the inner-ear semicircular canals to stabilize vision during head movement. Clinicians commonly assess this system with video head impulse testing, or vHIT, which evaluates the response to rapid, high-frequency head movements, and caloric testing, which stimulates the horizontal canals at ultra-low frequencies using warm or cool air or water. Both methods are clinically valuable, but neither fully represents the mid-frequency range used during many ordinary movements, such as walking, turning the head or riding in a vehicle.

Rotational chair testing is designed to examine this overlooked range. In a computer-controlled chair, a patient is rotated at carefully selected frequencies, typically from 0.01 to 0.64 hertz, while eye movements are recorded. These frequencies stimulate both horizontal semicircular canals simultaneously and allow clinicians to quantify the vestibulo-ocular reflex, the automatic response that keeps images stable on the retina when the head moves. Because the system delivers precisely controlled motion, it can produce highly reproducible measurements while avoiding the discomfort and nausea that some patients experience during caloric testing.

The review describes four principal measurements used to interpret rotational chair results: gain, phase, symmetry and time constant. Gain compares eye velocity with chair velocity and indicates how effectively the reflex compensates for head movement. Phase measures the timing relationship between the stimulus and the eye response, while symmetry compares the strength of responses between the two directions of rotation. The time constant reflects how long the response persists after stimulation and can provide information about the dynamics of the vestibular system. Together, these metrics may help distinguish damage originating in the inner ear from abnormalities involving central compensation in the brain.

The technology may be particularly useful for patients with bilateral vestibulopathy, a condition in which both sides of the vestibular system are impaired. Individuals with bilateral loss often experience blurred vision during walking, unsteadiness in darkness and difficulty maintaining balance on uneven ground. In some cases, caloric testing produces no measurable response, while rotational chair testing can detect residual low-frequency function. Identifying that remaining capacity could help clinicians estimate prognosis, select rehabilitation exercises and monitor whether therapy is producing measurable improvement.

The test may also add important information in presbyvestibulopathy, an age-related decline in vestibular function. Older adults frequently experience a combination of reduced inner-ear sensitivity, impaired vision, weaker proprioception and slower central compensation. Rotational chair testing can help quantify the vestibular component of that decline and may reveal deficits that are not obvious from bedside examination alone. In patients recovering from acute unilateral vestibular injury, repeated testing could show whether symptoms have improved because the damaged organ has recovered or because the brain has adapted to an ongoing imbalance.

That distinction is clinically significant. A patient may feel better even though vestibular function remains reduced, because the central nervous system has recalibrated visual, proprioceptive and vestibular signals. Conversely, persistent abnormalities in the low- or mid-frequency response may help explain why symptoms return when the patient is tired, moves quickly or encounters visually complex surroundings. By tracking gain, phase and symmetry over time, clinicians may be able to follow compensation more objectively rather than relying only on subjective reports of dizziness.

The review also highlights applications in groups that are difficult to evaluate with conventional methods. Children with hearing loss or congenital inner-ear malformations may have subtle vestibular deficits that remain undetected during routine assessment. Rotational chair testing can be performed without requiring the rapid, precisely timed head movements needed for vHIT, making it potentially useful for younger patients or individuals who cannot cooperate with standard procedures. It may also assist in evaluating cochlear implant recipients, patients with Ménière’s disease and people with vestibular migraine, where symptoms can be substantial even when conventional findings are inconsistent.

Another potential role lies in conditions that are not primarily caused by the inner ear. Cerebrovascular disease, persistent postural-perceptual dizziness and other disorders involving sensory integration or central processing can alter the way vestibular information is used. Rotational chair findings cannot identify every cause of dizziness, but they may provide physiological evidence of abnormal balance-system performance when imaging and routine examinations are inconclusive. The authors suggest that this could support more individualized vestibular rehabilitation, including exercises tailored to a patient’s specific frequency-dependent deficits.

Despite these advantages, rotational chair testing is not a standalone diagnostic solution. The review notes that the procedure cannot reliably lateralize a unilateral lesion by itself, because both horizontal canals are stimulated together. Equipment costs are also higher than those of some conventional bedside assessments, and widely accepted age-stratified normative databases remain limited. Results must therefore be interpreted alongside the patient’s history, neurological examination, hearing assessment, vHIT, caloric testing and, when appropriate, imaging. The authors call for multicenter studies to establish standardized reference ranges and consistent testing protocols. They also envision artificial-intelligence tools that could assist with interpretation and cloud-based systems that might bring sophisticated vestibular analysis into primary care. If these developments succeed, rotational chair testing could evolve from a specialized laboratory procedure into part of an integrated digital pathway for diagnosing dizziness, monitoring recovery and guiding personalized treatment.

Subject of Research: Vestibular disorders and the clinical application of rotational chair testing.

Article Title: Advances in the Clinical Application of Rotational Chair Testing for the Diagnosis and Management of Vestibular Disorders

News Publication Date: 24-Jun-2026

Web References: https://doi.org/10.15302/ENTD.2026.060002

References: ENT Discovery, DOI: 10.15302/ENTD.2026.060002

Keywords: rotational chair testing, vestibular disorders, dizziness, vertigo, vestibulo-ocular reflex, bilateral vestibulopathy, presbyvestibulopathy, vestibular rehabilitation, vHIT, caloric testing, Ménière’s disease, vestibular migraine