Last Updated: May 2026

Vestibular agnosia is present when a patient has BPPV with positional nystagmus but they cannot feel any vertigo during BPPV testing or treatment.

Primary complaints of patients I’ve seen with vestibular agnosia include unexplainable imbalance, dysequilibrium worse with certain triggering movements, and chronic falls or near falls.

As an example, an older adult with vestibular agnosia may seek my specialty consultation services for complaints of perpetual imbalance, worse with certain activities, and repeated falls. This patient will typically deny any dizziness or vertigo when we go over their history and current complaints before starting their initial evaluation.

Sometimes these patients have co-occurring health issues such as orthostatic hypotension or cervical subluxation. In those cases, the patients may complain of dizziness but they will still not complain of any spinning sensations even though they have BPPV.

In this blog, we will focus the details of our discussion on the classic case example of a patent with BPPV and vestibular agnosia, without any co-occurring secondary cause of dizziness.

Why is Vestibular Agnosia Being Missed?

As part of my comprehensive trademarked methodology, The Bell Method®️, I test all my patients for BPPV during the initial consultation.

However, many if not most general clinicians would not think to test for BPPV – or consider referring out for BPPV testing – if the patient is not complaining of dizziness or vertigo.

(Sadly, many general clinicians do not refer out for BPPV testing even if the patient IS complaining of dizziness or vertigo. This is the reason why so many dizzy patients with BPPV fall through the cracks of the health care system.)

Classically, BPPV causes spinning vertigo when lying down in bed, rolling over, sitting up in bed, and getting out of bed. Looking up, bending forward, and turning around may also cause dizziness or vertigo in classic cases.

This is what my patients and I call “motion-activated” dizziness or vertigo.

In the case of vestibular agnosia, the patient cannot feel their dizziness or vertigo. If I ask them about dizziness or vertigo explicitly, they typically state that they do not have any dizziness or vertigo. The primary complaint is imbalance and falls – or near falls.

Physiological Explanation for Vestibular Agnosia

You may be wondering how it’s possible for a patient to have BPPV but not to feel dizziness or vertigo. If you are familiar with BPPV, you already know that spinning vertigo is characteristic of patients with this condition.

BPPV is a condition of dislodged and displaced crystals in the semi-circular canal(s) of the inner ear (vestibular system).

Classically when a person with BPPV moves, the crystals swirl within the canal like a snow globe being shaken up. This causes a momentary discrepancy in vestibular sensations compared with the uninvolved ear.

This mismatch between the right and left ears causes motion-activated symptoms that typically resolve within one minute.

In order to sense the mismatch and thereby perceive “spinning vertigo” during the triggering positions or motions, the patient’s brain has to be working properly.

If the brain is not working properly, then the patient cannot usually perceive dizziness or vertigo but will experience dysequilibrium. They experience chronic imbalance that waxes and wanes.

If a patient has a mild traumatic brain injury (mTBI), a concussion, or degeneration of the brain later in life (neurodegenerative disorder with aging), then the brain cannot sense the vestibular mismatch.

The Status Quo of Health Care

In my opinion, all patients with symptoms like imbalance, dysequilibrium, falls, or near falls should be tested for BPPV.

Special attention to remain alert for possible vestibular agnosia should be given to patients with:

• Mild Traumatic Brain injury (mTBI)
• Concussion
• Older adults with unexplained falls
• Older adults with brain scan results (CT scan or MRI) showing chronic microvascular changes or other signs of neurodegeneration
• People with a family history of neurodegenerative disorders, such as Alzheimer’s and Parkinson’s disease

Sadly, it is not the gold standard of health care to test for BPPV with all older adults who fall or complain of imbalance.

This is one reason I believe that the status quo of health care needs to improve for patients with dizziness, vertigo, imbalance, or chronic falls.

What is the Treatment Plan for Vestibular Agnosia?

As part of The Bell Method®️, I think of the treatment plan for these patients as having two phases.

Phase I:

For my patients with vestibular agnosia, I treat the BPPV guided by the positional nystagmus until it resolves. They don’t feel any symptoms during the BPPV testing or treatment.

BPPV treatment utilizes crystal repositioning maneuvers, or Canalith (literally “ear stone”) Repositioning Maneuvers. The crystals need to be moved back to where they came from to resolve the BPPV symptoms by a vestibular health care provider.

After the BPPV is successfully treated, the patient with vestibular agnosia typically feels less wobbly and more stable with walking. They may even walk at a faster pace without realizing it. Their postural control and balance automatically improves when BPPV is resolved!

In the meantime while we are still in the treatment series aimed to resolve the BPPV, we implement safety and fall prevention strategies due to the risk of falling. Caregiver training and equipment may be needed in some cases.

The patient can also start home exercises like bladder control retraining for incontinence.

Home exercises the patient may need and can start right away for muscles include:

• foot and ankle exercises for strengthening and proprioception,
• core strengthening,
• glute muscle strengthening,
• bladder control retraining,
• stretching, and
• postural retraining.

If the patient does not already have a neurologist, I always refer these patients to a neurologist for a consultation to evaluate their brain health. If they don’t have a recent brain MRI, they should get one.

Our sessions usually include plenty of laughter as well, because laughter can help with healing. The stress of having an unexplained health condition can cause a lot of stress, so stress management is helpful.

What type of BPPV?

Older adults with vestibular agnosia typically have free-floating BPPV crystals in their posterior canal on one side, so it typically resolves in 1-3 BPPV treatments. If they have been experiencing imbalance for more than a few months while remaining very physically active, the loose crystals may have spread out to multiple locations in their inner ear over the course of time, so they may need more treatments to resolve it.

In general, patients with a history of traumatic brain injury or concussion, are more likely to have BPPV crystals scattered into more than one location within the vestibular system from the onset, such as multi-canal or bilateral BPPV. Clearing BPPV can take longer to resolve with complex post-traumatic BPPV presentations.

The eyes serve as a guide to direct BPPV treatments based on nystagmus during BPPV testing, since the patient does not feel dizziness or vertigo.

Phase II:

After the BPPV is resolved, the patient will notice improvement in their balance.

However, they will most likely still need a full course of neurological physical therapy to rehab the underlying brain problem. These physical therapy sessions must include challenging balance exercises.

For this phase of the treatment plan, I recommend a DPT with credentials NCS. This credential means the PT is Board-Certified in Neurological PT.

These patients typically require a high volume of neuro rehab, like 20-25 visits. The typical frequency is twice a week for 10-12 weeks.

What is the Prognosis?

Patients with vestibular agnosia can make significant improvements and increase their quality of life with BPPV treatment followed by neurological physical therapy. Now you can see why it’s a tragedy not to test for BPPV in all cases of patients with imbalance, chronic falls, or near falls.

The final level of recovery may be limited by the brain problem, so a full recovery may not be possible.

In older adults with neurodegenerative disorders, their balance may continue to decline gradually with aging as the brain continues to degenerate.

BPPV can recur anytime, so patients with a history of vestibular agnosia should seek BPPV re-evaluation in the future if their balance declines again. Another course of Phase I and/or Phase II above may be needed.

Learning about brain health and making appropriate lifestyle changes can be helpful for patients with vestibular agnosia.

Additional Resources

Learn more about BPPV treatment.

Search online to find a local vertigo doctor.

I also treat private patients in San Diego and have published a book for patients who are unable to work with me in person.