Vertigo testing starts with simple bedside maneuvers that can often pinpoint the cause within minutes. Depending on your symptoms, your provider may use a combination of physical exams, eye-movement recordings, balance assessments, and imaging to figure out whether the problem originates in your inner ear or your brain. Most people with vertigo never need advanced testing because a skilled clinical exam is remarkably accurate on its own.
The Dix-Hallpike Maneuver
If your vertigo comes in brief spells triggered by head movement, the first test you’ll likely encounter is the Dix-Hallpike maneuver. It’s the standard way to check for benign paroxysmal positional vertigo (BPPV), the single most common cause of vertigo. No equipment is required.
You’ll sit on an exam table and turn your head 45 degrees to one side. The examiner then quickly lowers you backward so your head hangs about 20 to 30 degrees below the table’s edge. You stay in that position while the examiner watches your eyes closely. If tiny calcium crystals in your inner ear have drifted into the wrong canal, your eyes will start making involuntary rhythmic movements called nystagmus within a few seconds. That eye movement typically lasts less than 30 seconds, beats upward with a slight rotation, and fades if the test is repeated. The whole sequence is then done with your head turned to the other side.
One detail worth knowing: some providers use Frenzel goggles, thick lenses that prevent you from focusing on a fixed point. Removing visual fixation makes the abnormal eye movements easier to spot. If you’ve ever been told a Dix-Hallpike was “negative” but you still feel dizzy, the test may be more revealing with goggles or when performed by a vestibular specialist.
The HINTS Exam for Stroke Concerns
When vertigo is continuous rather than triggered by position changes, providers need to determine whether the cause is a problem in the inner ear or something more serious like a stroke affecting the balance centers of the brain. A three-step bedside exam called HINTS (Head Impulse, Nystagmus, Test of Skew) does this with striking accuracy. In a landmark study published in the journal Stroke, this bedside exam was 100% sensitive and 96% specific for identifying stroke, actually outperforming early MRI in the first 24 to 48 hours.
Here’s what each step checks:
- Head impulse test. The examiner asks you to fix your gaze on their nose, then quickly turns your head to one side. If your eyes stay locked on target, your inner-ear reflex is working normally on that side. Counterintuitively, a normal result here is the worrisome one, because it suggests the inner ear is fine and the problem may be in the brain.
- Nystagmus pattern. The examiner watches whether your involuntary eye movements change direction when you look left versus right. Nystagmus that switches direction with gaze is a red flag for a central (brain-related) cause.
- Test of skew. Using a cover-uncover technique over each eye, the examiner checks for vertical misalignment. If one eye drifts up or down when uncovered, it points toward a brainstem problem.
Any one of those three “dangerous” signs can indicate a stroke. This exam is typically done in emergency departments, but it requires training to perform and interpret correctly.
Videonystagmography (VNG)
VNG is the most widely used laboratory test for vertigo. You wear goggles fitted with infrared cameras that track your eye movements in a dark room. The test has three parts, and the full session usually takes about 60 to 90 minutes.
During ocular testing, you follow moving lights and stare at steady lights without moving your head. This checks how well your brain coordinates eye movements. Positional testing involves moving your head and body into various positions while the cameras record whether any of those positions trigger nystagmus. Caloric testing is the part most patients remember: cool and then warm water or air is gently delivered into each ear canal. The temperature change stimulates the inner ear on that side, and your eyes should respond with a predictable pattern of movement. If one ear produces a significantly weaker response than the other, it suggests damage to the vestibular system on that side.
Caloric testing can make you temporarily dizzy and sometimes nauseated. That brief discomfort is actually the point of the test, since a normal response means the inner ear is functioning.
How to Prepare for VNG
Preparation matters because many common medications suppress the vestibular system and can produce falsely normal results. You’ll typically be asked to stop taking motion-sickness drugs like meclizine, as well as sedatives, anti-anxiety medications, antihistamines, sleep aids, and narcotic pain medications for a full 48 hours before the test. Don’t eat for two hours beforehand, since the caloric portion often causes brief nausea. If you’re diabetic and need to eat, keep it light. Skip caffeine and alcohol the day of your appointment as well.
Video Head Impulse Test (vHIT)
The vHIT is a newer, faster alternative that measures how well each of your six semicircular canals responds to rapid head rotations. You wear lightweight goggles with a high-speed camera while the examiner delivers quick, small head turns in different directions. The goggles simultaneously track your head velocity and eye movement, then calculate a ratio called VOR gain. A healthy horizontal canal produces a gain above 0.81, meaning the eyes compensate for nearly all of the head’s movement.
Compared to traditional caloric testing, vHIT is quicker, better tolerated, and tests all six canals rather than just the two horizontal ones. It’s also more sensitive and specific for detecting stroke in patients with acute dizziness. The tradeoff is that some inner-ear problems only show up at the very low frequencies that caloric testing stimulates, so the two tests sometimes complement each other.
Rotary Chair Testing
If your provider suspects both inner ears are affected, the rotary chair test is the gold standard. You sit in a motorized chair in a dark room while it rotates at controlled speeds and the system tracks your eye movements. By testing across a range of rotation frequencies, from very slow (0.01 Hz) to faster oscillations (0.28 Hz), it can detect residual function that other tests miss. A patient might show abnormal responses at low speeds but normal responses at higher speeds, which changes the treatment plan significantly.
Rotary chair testing is also a good option for children or for anyone who can’t tolerate caloric testing because of ear anatomy or severe motion sensitivity. It’s comfortable, and the rotation speeds are gentle.
Computerized Dynamic Posturography
This test doesn’t look at your eyes at all. Instead, it measures how well you keep your balance under increasingly tricky conditions. You stand on a platform that can tilt or shift while a visual surround moves around you. By selectively removing or distorting the information your body normally relies on (vision, the feeling of the floor under your feet, and inner-ear signals), the test isolates which sensory system is failing.
Your scores are compared against age-matched norms. The test also evaluates your automatic reflex responses to sudden platform movements, checking whether your motor system can recover balance quickly enough. Posturography is especially useful for guiding vestibular rehabilitation, because it shows your therapist exactly which sensory inputs you’re over-relying on or under-using.
Hearing Tests
An audiogram is a standard part of the vertigo workup because certain conditions damage hearing and balance together. Meniere’s disease, for example, requires documented hearing loss for diagnosis. The pattern is distinctive: people with Meniere’s disease typically lose hearing in the low frequencies, or in a combination of low and high frequencies, while midrange hearing stays relatively intact. A diagnosis also requires at least two vertigo episodes lasting between 20 minutes and 12 to 24 hours, along with tinnitus or a sensation of fullness in the affected ear.
When Imaging Is Needed
Most vertigo does not require an MRI or CT scan. Imaging becomes important when bedside testing can’t clearly distinguish a peripheral (inner-ear) cause from a central (brain) cause, or when there are neurological symptoms alongside the dizziness, like weakness, numbness, difficulty speaking, or severe headache.
MRI is the preferred scan because it can reveal tumors in the back of the brain, small strokes in the brainstem or cerebellum, structural abnormalities like Chiari malformations, and demyelinating lesions from conditions like multiple sclerosis. CT scans are less useful for most vertigo causes but play a role in the emergency department when sudden-onset symptoms raise concern for bleeding in the brain.
If your vertigo is clearly positional, lasts seconds, and resolves with the right repositioning maneuver, imaging adds nothing. If it’s persistent, accompanied by new neurological symptoms, or doesn’t fit a recognizable inner-ear pattern, imaging helps rule out the rare but serious causes.