Dizzy After a Concussion? Why a Comprehensive Vestibular Evaluation Matters

“Dizzy” is one of the most common words people use after a concussion—and one of the least precise. It can mean spinning, rocking, swaying, floating, tilting, nausea, visual motion sensitivity, or the unsettling sense that the world has shifted around you. Those differences matter because they point to different systems and different next steps.

In Episode 40 of Life After Impact: The Concussion Recovery Podcast, I speak with Dr. Helena Esmonde, founder of Vestibular First. Her message is simple but important: a person with post-concussion dizziness should not have to settle for a vague label or a generic home exercise sheet. Comprehensive vestibular rehabilitation begins with figuring out what is actually driving the symptom.

The Same Word Can Describe Very Different Experiences

Some people describe a spinning room. Others say they feel as though they are on a boat, walking on a trampoline, being pulled sideways, or watching the world jump when they move their head. A clinician who only asks, “Are you dizzy?” may miss the clues hidden in the quality, timing, triggers, and duration of that sensation.

The experience can also change over time. In the early days after concussion, a person may have acute positional vertigo. Months later, the primary issue may be gaze instability, visual dependence, neck-related dizziness, autonomic dysregulation, persistent postural-perceptual dizziness (PPPD), or a combination of several systems. The goal is not to force every experience into one diagnosis; it is to determine which pattern is present now.

BPPV Can Be Present—and Easy to Miss

Benign paroxysmal positional vertigo, or BPPV, happens when tiny calcium crystals in the inner ear move into a canal where they do not belong. It often causes brief but intense vertigo with position changes, such as rolling over, getting out of bed, bending down, or looking upward.

After head injury, BPPV may involve more than one canal or appear alongside other vestibular and visual problems. It can also be missed if positional testing is incomplete or if the eyes are not observed clearly enough during the maneuver. A negative screen is only useful when the testing itself was thorough.

The VOR Is Only One Part of the Story

The vestibulo-ocular reflex (VOR) helps keep vision stable when the head moves. When it is impaired, walking, driving, reading signs, scanning shelves, or turning the head can make the world appear to bounce or lag. VOR testing is valuable, but it is not a complete vestibular examination.

Balance requires information from the inner ear, eyes, neck, feet, muscles, brainstem, cerebellum, and cortex. A complete evaluation may consider gaze stability, eye movements, positional testing, balance under different sensory conditions, visual motion sensitivity, cervical contribution, and how symptoms behave in real life—not only on one exercise.

Why Infrared Goggles Can Change the Evaluation

Vestibular clinicians sometimes use infrared goggles to observe eye movements in darkness. This can make subtle nystagmus—the involuntary eye movement that may help identify a vestibular pattern—far easier to see than it would be in ordinary room light.

The technology does not replace clinical reasoning, but it can give the clinician better information. In a complicated post-concussion case, better observation can be the difference between repeatedly treating a guessed-at diagnosis and finding a meaningful pattern that was hiding in plain sight.

Persistent Dizziness Is Not “Just Anxiety”

Persistent postural-perceptual dizziness, or PPPD, can develop after a vestibular event, concussion, migraine, panic, or another destabilizing experience. It often includes chronic non-spinning dizziness, unsteadiness, heightened sensitivity to motion or complex visual environments, and symptoms that worsen when upright.

PPPD is not a dismissal of the person's experience. It is a recognized pattern involving how the brain processes balance, motion, and threat. Treatment may include carefully dosed vestibular rehabilitation, visual-motion work, nervous-system regulation, and support for the emotional load that can accompany persistent symptoms.

More Exercises Are Not Always Better

Vestibular rehabilitation often requires exposure to movements that temporarily provoke symptoms. But “push through it” is not the same thing as appropriately dosed rehabilitation. An exercise can be too easy to create change, too difficult to recover from, or simply aimed at the wrong system.

Precision matters. A good plan should explain what the exercise is intended to train, how symptoms should respond during and after it, how often to do it, and when the plan should be adjusted. Your response to treatment is useful clinical data—not evidence that you have failed rehabilitation.

A Better Question Than “Why Am I Still Dizzy?”

A more useful question may be: Which parts of my balance system have been evaluated, and which have not? For some people, the answer is a straightforward BPPV maneuver. For others, recovery involves retraining the VOR, addressing visual motion sensitivity, treating migraine, improving cervical input, working with autonomic regulation, or rebuilding confidence in movement. The point is not to make dizziness seem complicated; it is to make the evaluation complete enough to find the right next step.

This article is educational and is not a substitute for individualized medical advice. If dizziness is new, worsening, severe, associated with fainting, weakness, double vision, severe headache, or other safety-affecting symptoms, seek prompt evaluation from an appropriately qualified healthcare professional.