"Normal" Is a Starting Point, Not a Verdict

By Dr. Georgine Nanos, MD, MPH — Founder & CEO, Kind Health Group, Encinitas, CA

I'll be honest about something. When a patient tells me she's dizzy, my heart sinks a little.

Not because I don't want to help her. Because dizziness is one of the hardest complaints in all of medicine to sort out, and I've been doing this a long time, and I know before we start that this is going to take real work. And I also know she has probably already been somewhere else and been told nothing is wrong.

So I had Dr. Kim Bell on the podcast, and she is the person you call when everybody else has run out of answers. She's a vestibular physical therapist, she's spent more than twenty years on this one problem, she got certified in clinical vestibular competency through Johns Hopkins, and her patients call her the Vertigo Detective. They fly in from other countries to see her. Right now she is somebody's twentieth opinion.

Twentieth.

And she opened with a story I have not been able to put down.

Twenty years and almost every bone

Her very first vertigo patient, back in 2006, was a woman in her mid-seventies who had been dizzy for twenty years. Since her mid-fifties.

Over those twenty years she had broken almost every bone you can think of from falling. Her shoulder. Her wrist. Her hip. Her foot. She was completely homebound by the end of it, she couldn't drive, and the only time she left her house was in an ambulance on her way to have the next fracture set.

Kim had just taken a single Saturday training class. She told the woman honestly that she had never treated this before but she would try. And she put her training manual open face-down on the bed, in this woman's house in Chula Vista, and worked through it.

Three sessions. The vertigo was gone. Completely gone.

Then eight weeks of ordinary physical therapy to get her strong enough to do the things she hadn't done in two decades, carrying groceries in from the car, getting up and down her own stairs. And then she started driving again. And she started handing Kim's business card to everyone she knew.

At one point she looked at Kim and said, do you understand, you gave me my life back.

Twenty years. Fixed in three visits. And I want to sit in that for a second, because the thing I keep thinking about is not the happy ending. It's the nineteen and a half years.

What she was almost certainly told

Here's what I know without being in the room, because I see it every week with different symptoms.

That woman went to doctors. Over twenty years, of course she did, she was in the emergency department constantly with fractures. And somewhere in there she had scans and labs. And they came back normal, and she was told there was nothing wrong.

And she heard what everybody hears. Nobody can help me. This is just my life now.

So let me say the thing I say in my exam room several times a week.

Normal test results are not a dismissal. They are a starting point.

When your MRI is clean and your labs are clean, that is genuinely good news, and Kim actually loves those cases for exactly this reason. It means the dangerous things have been ruled out. No tumor. No stroke. Nothing on your heart. What it does not mean is that nothing is wrong with you. It means the cause is somewhere nobody has looked yet.

And Kim said the part I found harder to hear, which is that when a provider runs out of answers, they very often hand the patient a psychological explanation instead. It must be anxiety. It must be stress.

Her response to that was so good. She said, maybe you are anxious. Of course you're anxious. You're a human being with a mystery condition and anyone would be. But anxiety is not what the exam found. Anxiety is what happens when the exam ends.

To every woman who has been handed that: you are not imagining this. Being frightened by a symptom nobody can explain is the most reasonable response available to you.

The reason nobody found it is almost stupidly mechanical

This is the part of the conversation that genuinely changed how I think about dizziness, and I want to explain it carefully because once you understand it you'll never let anyone wave you off again.

The single most useful sign in diagnosing vertigo is a specific involuntary jitter of the eyes called nystagmus. The eyes bounce, the patient isn't doing it on purpose, and the pattern of the bounce tells a trained clinician which ear, which canal, and what kind of problem.

Here's the catch. Your visual system suppresses it.

When you're sitting in a normally lit exam room and you fix your eyes on the doctor's face or a spot on the wall, your vision locks in and steadies your eyes. Positional nystagmus gets suppressed in room light by as much as sixty-six percent in patients with BPPV who are tested without blocking fixation.

Sixty-six percent. Of the one sign that gives the answer.

So the exam that finds it has to happen in the dark. You put on a headset that looks like virtual reality goggles, the patient sees nothing at all, and infrared cameras film their eyes in the blackness. Kim said as soon as those goggles go on it shows her so much, and I believe her, because she's describing removing the thing that was hiding it.

And then she said the sentence that explains twenty years of broken bones. General neurologists don't use this equipment. General ear nose and throat doctors don't use it either. There's a subspecialty, oto-neurology, and another one within ENT called neurotology, and by her count there are two of those doctors practicing in all of San Diego County. That's her professional observation rather than something I can look up, but the general shape of it is easy to confirm. This is rare equipment in rare hands.

She didn't own the goggles herself for her first seventeen years. She treated people successfully anyway, on educated guesses and trial and error, eight or ten visits at a time. She bought them after the Johns Hopkins training in 2023, and now the same work takes two or three visits, because she can see it instead of inferring it.

That is a twenty-year-old woman's worth of difference sitting inside a piece of equipment.

What the crystals actually are

Let me explain the most common cause, because the mechanism is genuinely satisfying and almost nobody gets told it.

BPPV stands for benign paroxysmal positional vertigo, and it is the most common inner-ear cause of vertigo there is. What it means in plain language is that there are crystals loose in your inner ear.

They're real. Calcium carbonate crystals, called otoconia, and they belong in one part of the inner ear where they help your brain sense gravity and motion. Sometimes they come loose and drift into the semicircular canals, which are a set of curved tunnels filled with fluid. Now every time you move your head, these loose crystals slosh through fluid they were never supposed to be in, and your brain gets a violent signal that you are spinning.

That's it. That's why you spin when you roll over in bed, or sit up, or look up at a high shelf, or bend over. Those are the classic positions and if you're nodding along at them, take that list to somebody.

And the treatment is mechanical, which I love. Kim described it as playing a pinball game with the patient's head, which is the best description of the Epley maneuver I have ever heard. The fluid in there is thick, roughly the consistency of motor oil, and the crystals only fall straight down with gravity, same as anything you drop. So a clinician tilts your head into a position, waits for the crystals to sink, tilts you again, waits again, and walks them back around the loop to where they belong.

The Epley maneuver was published in 1992 by Dr. John Epley, and it resolves posterior canal BPPV in roughly eighty to ninety percent of patients within one to three treatments. Which is why that woman was better in three sessions. That's not a miracle, that's the expected result. The miracle was that somebody finally did it.

There are more canals and more variants than Epley's original maneuver covers, and there are research teams around the world working out the maneuvers for each of them. But the principle is the same everywhere: you are moving a small stone through fluid using gravity and patience.

One more thing worth knowing. Kim also treats the version where the patient clearly gets dizzy during testing but shows no visible eye movement at all. Most clinicians see no nystagmus and send the patient home saying it must not be BPPV. Her mentor told her years ago to just run them through the maneuver and see what happens, and it works. The literature calls it BPPV without nystagmus, or subjective BPPV, and symptom remission runs somewhere from fifty to ninety-seven percent. So the absence of the visible sign is not the absence of the condition, and it is not a reason to send you away.

Now here's what nobody said out loud, and it's the part that's yours

Kim mentioned, almost in passing, that women in their fifties are the most common group to develop vertigo spontaneously. Her very first patient started at fifty-five.

Nobody explained why. So I went and read, because I wanted to know whether that was a coincidence and it absolutely is not.

There are estrogen receptors in your inner ear.

Estrogen directly regulates the calcium metabolism of the otoconia, the crystals themselves. And when estrogen falls, the protein matrix that holds those crystals in place degrades. They become more fragile. They come loose more easily.

Read that again, because it reframes everything. The reason vertigo shows up in your fifties is the same reason your sleep changed and your skin changed and your bones changed. It is not bad luck and it is not aging generically. It is the same hormonal shift, showing up in an organ nobody thinks to connect to it.

And it keeps going, in a direction that's actually useful.

Lower bone mineral density is associated with getting BPPV and with getting it again. Low vitamin D is associated with developing it in the first place. And in people who have both BPPV and a low vitamin D level, correcting the vitamin D and calcium reduces how often the attacks come back.

Spontaneous BPPV occurs most often between fifty and seventy, and it's about twice as common in women. That's not a mysterious pattern once you know estrogen is holding those crystals down.

So if you are a woman in your fifties who is spinning every time she rolls over in bed, here is what I want for you. Get the maneuver, absolutely, from someone who knows what they're doing. But do not let it end there. Somebody should be checking your vitamin D. Somebody should be asking about your bone density. Somebody should be looking at where you are hormonally and treating this as connected to it, because it is connected to it.

This is the whole thing I care about most. Midlife symptoms get handed out one at a time to specialists who never speak to each other. The dizziness and the bone loss and the hormones are one conversation, and almost nobody is having it as one conversation.

Where medication fits, and where it doesn't

Quick, because it matters and people get this wrong in both directions.

Kim was clear that there are skillful ways to use medication for vertigo and that it's genuinely necessary in a lot of cases. She's not anti-medication and neither am I.

But medication cannot reposition a crystal. If there's debris loose in a canal, no pill moves it back. It can make you more comfortable while you're waiting, and that has real value when someone is vomiting and terrified. It is not the treatment.

So if you have been on a vertigo medication for months or years and nobody has ever put you through a positional test, that is the gap. Not the prescription. The thing that was supposed to happen alongside it.

What she'd want you to hear

I asked what she'd say to someone who is genuinely at the end of it, discouraged, ready to stop looking.

She said don't give up hope, and then she got specific in a way I appreciated. She said the qualities that get people through this are optimism, resilience, and mental fortitude, and she defined mental fortitude as carrying on without knowing exactly what you're doing. Just not quitting. Not settling for taking a medication for the rest of your life and calling that an answer.

And then she gave the practical version, which is the part you can act on this week.

Write it down before you go. She gives every new patient a set of questions before she'll even schedule them, and there are three that matter most: the onset, meaning what were you doing when you first felt it. The trigger, meaning what were you doing right before. And the duration, meaning how long it lasted. She has patients write it up chronologically and send it to her, and she says by the time they walk in she usually already has an idea. She has a free version of that tool on her sites. Take it to your own doctor, not just to a specialist.

Follow through on the referrals. She said patients get discouraged and stop completing the plan, and then there's nothing further their doctor can do. If a test was ordered, get it. If a referral was made, book it.

And then ask for the right room. Ask specifically for someone who specializes in the vestibular system and who has infrared video goggles. It can be a physician, a nurse practitioner, a physician assistant, or a physical therapist. The credential matters less than the specialty and the equipment.

The best advice she ever got came from her mentor at Johns Hopkins, and it was three words. Follow the eyes.

What I actually want you to take from this

That woman spent twenty years believing her body had turned on her, and the answer was a fifteen-minute maneuver that nobody performed because the sign that pointed to it was only visible in a dark room.

I think about how many people are sitting in that gap right now. Kim said something that has stayed with me, that when a patient says "I'm dizzy," the doctor almost has a mini heart attack and thinks, not another one. And she's right, and I've felt it, and I told her so on the show. It's not that we don't care. It's that we hit the edge of what we know, and then a lot of us don't even know there's a specialist to send you to.

That's a systems failure, and you should not have to pay for it with your years.

So take the list. Onset, trigger, duration. Write it down before your appointment. Ask whether anyone has done a positional test with your fixation blocked. If you're a woman in your fifties, ask for your vitamin D and ask someone to connect this to your hormones instead of treating it like a standalone glitch.

And when someone tells you your tests are normal, hear it correctly. That's the good news. That's the dangerous things being ruled out. It is the beginning of the search, not the end of it.

You are not crazy, you were never crazy, and the room really is spinning.

It's all fixable. Sometimes in three visits, which is the part that makes me a little furious and a lot hopeful at the same time.

Dr. Georgine Nanos is a board-certified family physician and the founder of Kind Health Group in Encinitas, California, where she practices comprehensive concierge and preventive medicine for women and men who are tired of being told everything looks fine.

This conversation is from The Kind Revolution podcast with guest Dr. Kim Bell, PT, DPT, a vestibular physical therapist in North County San Diego known as The Vertigo Detective. Her practice is at betterbalanceinlife.com and her free Vertigo Tool is at vertigodetective.com. Also available on Apple Podcasts, Spotify, Amazon Music, and YouTube. Search "The Kind Revolution."

This article is for education and is not medical advice. Dr. Bell is a physical therapist, not a physician. Talk to your own physician about your situation.

Frequently Asked Questions

What does it mean if I am dizzy but all my tests came back normal?

It means the dangerous causes have been ruled out, which is genuinely good news, and that the actual cause has not been found yet. Normal imaging and labs do not detect the most common causes of vertigo, which originate in the inner ear and are diagnosed by physical examination rather than by scans. A normal brain MRI also does not rule out a concussion, which is diagnosed clinically. Normal results are a reason to keep looking with a different kind of examination, not a reason to conclude that nothing is wrong.

What is BPPV?

BPPV stands for benign paroxysmal positional vertigo, and it is the most common inner-ear cause of vertigo. Small calcium carbonate crystals called otoconia, which normally sit in a part of the inner ear that senses gravity, come loose and drift into the fluid-filled semicircular canals. Head movement then sloshes them through fluid where they do not belong, producing a strong false sensation of spinning. Typical triggers include rolling over in bed, sitting up, getting out of bed, looking up, and bending over.

Why do doctors miss BPPV so often?

Largely because the key diagnostic sign can be hidden during a standard examination. Positional nystagmus, the involuntary eye jitter that identifies the condition, is suppressed by as much as 66% in normal room light when a patient can fix their eyes on a visual target. Detecting it reliably requires infrared video goggles that remove vision entirely while cameras film the eyes in darkness, and most general neurologists and general ENT clinics do not use this equipment. BPPV can also be present with no visible eye movement at all, in which case many clinicians incorrectly rule it out.

How effective is the Epley maneuver?

The Epley maneuver, published in 1992 by Dr. John Epley, resolves posterior canal BPPV in approximately 80% to 90% of patients within one to three treatments. It works by using gravity to move displaced crystals back to where they belong, with pauses between head positions because the inner-ear fluid is thick and the crystals fall slowly. Recurrence occurs in roughly 10% to 30% of patients within a year, with higher risk in older adults and in people with head trauma, osteoporosis, or low vitamin D.

Why is vertigo more common in women in midlife?

Because estrogen is involved in holding the inner-ear crystals in place. The inner ear contains estrogen receptors, and estrogen regulates calcium metabolism in the otoconia. When estrogen declines, the protein matrix securing those crystals degrades, making them more fragile and more likely to dislodge. Spontaneous BPPV occurs most often between ages 50 and 70 and is roughly twice as common in women. This makes vertigo in midlife part of the same hormonal picture as changes in bone density, sleep, and skin, rather than an unrelated problem.

Can vitamin D affect vertigo?

Yes, and it is worth testing. Lower serum vitamin D levels are associated with developing BPPV, and reduced bone mineral density is associated with both occurrence and recurrence. In people who have BPPV together with a below-normal vitamin D level, supplementing vitamin D and calcium carbonate has been shown to reduce further attacks. Anyone with recurrent BPPV, particularly a woman in or past the menopausal transition, has good reason to have vitamin D and bone density evaluated rather than treating each vertigo episode in isolation.

Can medication cure vertigo?

No, though it has a legitimate role. Medication can reduce nausea and distress during an acute episode, which matters a great deal when someone is severely symptomatic. It cannot move a displaced inner-ear crystal back into position, so it does not resolve BPPV. Anyone who has taken vertigo medication for an extended period without ever undergoing positional testing is missing the step that actually treats the underlying cause.

What should I bring to an appointment for dizziness?

Three specific pieces of information, written down in chronological order: the onset, meaning what you were doing when you first felt it; the trigger, meaning what you were doing immediately before it started; and the duration, meaning how long each episode lasts. Patients frequently have more than one cause, each with its own pattern, so noting them separately helps. It is also reasonable to ask directly whether positional testing has been performed with visual fixation blocked, and to request referral to a clinician who specializes in the vestibular system and uses infrared video goggles.