Epidemiology of disequilibrium

By Marcello Cherchi, MD PhD

For patients

The symptom of disequilibrium (and all its descriptors such as dizziness, vertigo, lightheadedness, unsteadiness, etc.) is very common, though it is difficult to come up with precise numbers for several reasons.  Disequilibrium from any cause can reduce a person’s quality of life, and drive them to seek health care, incurring significant personal and societal cost.

For clinicians

Overview

It is difficult to study the epidemiology of the symptom of disequilibrium for a variety of reasons.  Despite these difficulties, available literature makes clear that this symptom incurs significant health care costs and societal burdens.  A better understanding of this epidemiology should influence medical practice and public policy to improve care.

Introduction

The literature regarding the epidemiology of disorders of equilibrium is nascent.  Papers studying this problem at the population-based level have approached this problem from numerous different perspectives (Agrawal et al. 2009; Bisdorff et al. 2013; Cherchi 2013; Lai et al. 2011; Mendel et al. 2010; Mitchell and Bhattacharyya 2023; Neuhauser 2007; Neuhauser and Lempert 2009; Penger et al. 2017).  A masterful overview is provided by Dr. Hannelore Neuhauser (Neuhauser 2016).

Why is it difficult to arrive at good epidemiological data for this?

There are several reasons why it is difficult to study the epidemiology of disequilibrium.

Two of the greatest impediments in the study of otoneurological and neuro-otological conditions arise from the extraordinarily poor correlation between language and pathology.  Specifically:

• Terminological. The actual words used by patients and practitioners (dizziness, vertigo, lightheadedness, unsteadiness) have been repeatedly shown to have little to no correlation with final diagnoses (Kerber and Newman-Toker 2015; Newman-Toker and Edlow 2015; Stanton et al. 2007).
  • This is reflected in observations such as those by Yin and colleagues who conducted a retrospective review of 2169 patients complaining of “vertigo” and found that there were over 50 ultimate distinct diagnoses associated with this single chief complaint.
  • Perhaps unsurprisingly, it also leads to commentary such as, “Dizziness is the quintessential symptom presentation in all of clinical medicine. It can stem from a disturbance in nearly any system of the body.  Patient descriptions of the symptom are often vague and inconsistent” (Kerber and Baloh 2011).
  • This makes it more difficult to study than health experiences in which there is usually greater terminological uniformity, such as “knee pain.”
• Subjectivity. The reported symptom is, of course, entirely subjective.  This makes it more difficult to study than, say, an objective finding such as the presence/absence of hypertension.

Additional difficulties, not unique to otoneurology and neuro-otology, include:

• Different methodologies between studies.
• A variety of biases in data collection, such as selection bias and information bias (Neuhauser 2016).
• Differences in populations studied, such as:
  • Pediatric (Balatsouras et al. 2007; Choung et al. 2003; Humphriss and Hall 2011; Niemensivu et al. 2006; Riina et al. 2005).
  • Elderly (Figtree et al. 2021; Gassmann and Rupprecht 2009; Gopinath et al. 2009; Jonsson et al. 2004; Maarsingh et al. 2010a; Maarsingh et al. 2010b).
• Differences in practice setting (Adams and Marmor 2022), such as:
  • Primary care (family practice, general internal medicine) (Dominguez-Duran et al. 2021; Hanley and O’Dowd 2002; Maarsingh et al. 2010a; Maarsingh et al. 2010b; Sloane 1989; Yardley et al. 1998).
  • Neurology (Macrae 1960).
  • Otolaryngology (Arya and Nunez 2008; Guilemany et al. 2004; Isaradisaikul et al. 2010; Muelleman et al. 2017; Wells and Yande 1987).
  • Multidisciplinary clinic (Bath et al. 2000; Kim et al. 2020; Nedzelski et al. 1986)
  • Multiple outpatient settings (Kroenke et al. 1992).
  • Emergency department (Cheung et al. 2010; Navi et al. 2012; Newman-Toker et al. 2008).
• Differences by country.

How common are disorders of equilibrium?

Setting aside for a moment the difficulties mentioned above, it is nevertheless informative to review some numbers to get at least a general sense of the magnitude of this problem.

A survey of 20 European countries published in 2017 concluded that the average 6-month prevalence of “dizziness” was 12.4% (range 6.5% – 23.4%) (Penger et al. 2017), meaning that in these European countries, in any 6-month period about 1 in 8 people experiences dizziness at some point.

A study of “balance disorder trends” in the United States (Mitchell and Bhattacharyya 2023) found that:

• In 2008, 24.2±0.7 million people reported having experienced balance problems in the past 12 months; the US population in 2008 was about 304 million (https://hcup-us.ahrq.gov/db/nation/nis/NIS_Introduction_2008.jsp#figure9, https://hcup-us.ahrq.gov/figures/nis_figure9_2010.jsp, accessed 11/27/25), meaning that in 2008, about 8.0% of people in the US experienced balance problems.
• In 2016, 36.8±1 million people reported having experienced balance problems in the past 12 months; the US population in 2016 was about 314.6 million (https://hcup-us.ahrq.gov/db/nation/nis/NIS_Introduction_2016.jsp#figure1app1, https://hcup-us.ahrq.gov/figures/nis_figure1_2018.jsp, accessed 11/27/25), meaning that in 2008, about 8.6% of people in the US experienced balance problems.

From these figures we can calculate that over the course of 8 years (2008 – 2016), the proportion of people in the US who had experienced balance problems in the preceding 12 months increased by 7.5% ([8.6% – 8.0%] ÷ 8.0%), amounting to an increase of about 0.94% per year.

Cost due to health care utilization

The symptom of disequilibrium incurs significant costs through health care utilization.  In the United States alone, every year this symptom drives millions of people to seek medical attention, costing tens of billions of dollars.

In the emergency department setting:

• A study of hospital data from 1993 – 2005 found that every year about 3.3% of emergency room visits were for the symptom of dizziness (Newman-Toker et al. 2008). This means that about 1 in every 30 patients in the typical emergency department is there for the symptom of dizziness.
• In 2011 about 3.9 million emergency department visits were for dizziness (Saber Tehrani et al. 2013).
• A study in 2016 reported that the cost of evaluating and treating the symptom of dizziness in the emergency department setting alone cost over $10 billion per year (Newman-Toker 2016).
• A study in 2021 estimated that the total annual medical expenditure for patients with dizziness was $48.1 billion (Ruthberg et al. 2021).

In the outpatient setting:

• A cross-sectional analysis of data from the National Ambulatory Medical Care Survey found that from 2013 – 2015 there were 20.6 million outpatient visits for dizziness. This means that in the United States in that 3-year period there was an average of 6.9 million ambulatory care visits per year for dizziness.

The above figures pertain to utilization of health care services — in other words, people who became patients by consulting with a health care provider.  It is sobering to consider that only about half of people with this symptom seek medical care (Neuhauser 2016; Roberts et al. 2013).

Cost due to lost productivity and reduced quality of life

Benecke and colleagues (Benecke et al. 2013) analyzed a registry of 4294 patients from 618 medical centers in 13 countries and reported that:

• 8% of patients had reduced their workload
• 3% of patients had lost working days
• 6% of patients had changed employment
• 7% of patients had quit their jobs

Kovacs and colleagues (Kovacs et al. 2019) conducted a systematic review that included 16 studies from 2008 – 2018.  They reported that of patients whose “vertigo” compelled them to miss work, lost work time ranged from 13.1 days (over a 3-month period) to 69 days (over a 12-month period).

There is a paucity of validated instruments for assessing quality of life in patients with vestibular disorders (Duracinsky et al. 2007; McCaslin et al. 2025), though some investigators (Mira 2008) have extrapolated from existing metrics such as the Dizziness Handicap Inventory (Jacobson and Newman 1990) and Vestibular Disorders Activities of Daily Living Scale (Cohen and Kimball 2000).  Other obvious factors that can reduce quality of life include sequelae of disequilibrium, such as falls and reactive psychiatric conditions.

Why does this matter?

Having good estimates of the epidemiology of disequilibrium can facilitate medical practice and public policy at various levels, including:

• Medical practice
  • Differential diagnosis in the day-to-day clinical work of health care providers.
  • Medical education. For example, epidemiological data this may inform choices about how much (and what kinds of) exposure is appropriate in the training curricula of various medical specialties, or whether it is worthwhile to develop subspecialty board certification programs.
  • Medical resource allocation. For example, epidemiological data may guide rational use of imaging in the emergency department setting.
• Public policy
  • Allocation or incentivization of health care professionals to target systems or geographic areas where the need for care is greatest.
  • Public education. In the US, public initiatives have encouraged attention-raising media campaigns for diseases such as myocardial infarction and stroke.  Epidemiological data may encourage similar programs for the symptom of disequilibrium, since it has been estimated that only about half of people with symptoms of disequilibrium do not seek medical evaluation (Neuhauser 2016; Roberts et al. 2013).

Conclusions

A number of factors make it difficult to study the epidemiology of disequilibrium, including terminological inconsistencies, subjectivity of descriptions, different study methodologies, biases in data collection, differences between practice settings and specialties, differences by country and others.  Despite those difficulties, studies make clear that disequilibrium (in all its forms) comprises a health problem that is both common and imposes significant impairment, incurring direct costs of health care utilization, and indirect costs of lost productivity and reduced quality of life.  Greater understanding of the epidemiology of disequilibrium will have implications for medical practice and for public policy.

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