Specialist article: balance
Dizziness and Ménière’s diseaseWhat the middle ear and head balance have to do with it
Is everything spinning, is the floor swaying, does your head feel as if it were wrapped in cotton wool? Here you can find out which forms of dizziness there are, when dizziness is an emergency, what characterises Ménière’s disease and why, in our view, the middle ear and head balance are part of balance.
Does this sound familiar?
The floor sways, and nobody finds anything?
What applies to you?
Tap whatever applies to you.
Dizziness has many causes, some of them serious. New, severe or persistent dizziness should therefore be seen by a doctor. Once anything threatening has been ruled out, in our view it is worth looking at the middle ear, neck and head balance. These functions can be trained.
When dizziness is an emergencyWhat the middle ear has to do with itThe key points at a glance
- Dizziness is common. In a German population study, almost one in four adults had moderate or severe dizziness in the previous year. The causes range from harmless positional vertigo to stroke.
- Sudden dizziness with paralysis, speech or vision problems, a severe headache or unsteady gait is an emergency. Then call the emergency number 112.
- Balance arises from the signals of the inner ear, neck and eyes. In our view, pressure equalisation in the middle ear and head balance play a role in this, and both depend on the basic functions of breathing, swallowing and head balance. If you follow this logic, the training can create the conditions under which dizziness can improve, provided it is connected with this interplay.
Video
Dizziness: recognising causes, training functions
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Context
Dizziness: common, distressing, often unexplained
Almost everyone knows dizziness after a merry-go-round, after getting up too quickly or after one drink too many. For many people, however, it does not remain the exception.
Dizziness is not a disease in its own right but a set of symptoms with many possible causes. People describe it very differently: as rotational vertigo, like on a merry-go-round, as swaying dizziness, like on a boat, as brief positional vertigo when turning over in bed, or as light-headedness, where the head feels wrapped in cotton wool. This description is important for the assessment, because each form points in a different direction.
of adults had moderate or severe dizziness in the previous twelve months, based on data from 4,869 people in Germany1
had dizziness originating from the organ of balance in the inner ear1
of those with dizziness originating from the organ of balance reported a diagnosis that did not match it1
So dizziness is not infrequently misclassified. On top of this come the cases in which the examinations show nothing abnormal.
This is exactly where it is worth looking at balance as a system. It is a calculation performed by the brain, and it depends on more than the inner ear.
Safety
When dizziness is an emergency
By far the majority of dizzy spells are not dangerous. A few are, and you should be able to recognise them.
Call the emergency number 112 without hesitation if dizziness comes on suddenly and one of these signs is added: paralysis, weakness or numbness on one side of the body, a drooping corner of the mouth, slurred speech or difficulty finding words, double vision or sudden vision problems, a severe, unfamiliar headache, you can no longer stand or walk safely, light-headedness up to loss of consciousness, chest pain or a racing heart. These can be signs of a stroke or a cardiovascular disorder. Do not wait to see whether it gets better on its own.
Emergency number 112
Dizziness with one of the warning signs above, a first-time severe persistent dizziness in which you can no longer walk, or dizziness after a fall onto the head.
The same day
Suddenly worse hearing in one ear, with or without dizziness. Sudden hearing loss should be seen promptly by an ENT practice.
Have it checked soon
Recurring attacks, dizziness with tinnitus or ear pressure, after a new medication or persisting for days.
of people over 44 who came to the emergency department with dizziness or unsteady gait in an American population study had a stroke or a transient circulatory disorder in the brain, 53 of 1,6662
was the figure when the dizziness occurred without any other neurological signs2
So a stroke is rare with dizziness, but it does happen, and it usually reveals itself through accompanying signs. So pay attention to what comes along with it. Once anything threatening has been ruled out, the question is no longer whether the dizziness is dangerous, but what is disturbing your balance in the long term.
Forms of dizziness
The most common forms at a glance
Very different processes lie behind the word dizziness. The classification helps to find the right assessment.
Benign positional vertigo
Short, intense attacks of rotational vertigo when lying down or turning over in bed. They are triggered by tiny crystals that have got into a semicircular canal.
Loss of an organ of balance
Sudden rotational vertigo lasting days, with nausea, often after an infection. This is referred to as vestibular neuritis. It must be distinguished from a stroke by a doctor.
Ménière’s disease
Recurring attacks of rotational vertigo lasting hours, accompanied in one ear by fluctuating hearing, tinnitus and a feeling of pressure.
Central dizziness
The dizziness arises in the brain itself, for example with circulatory disorders, vestibular migraine or diseases of the cerebellum.
Circulation and metabolism
Blacking out when getting up, light-headedness with low blood pressure, low blood sugar, anaemia or due to medication.
Functional dizziness
Persistent swaying or light-headedness, worse when standing and in busy surroundings. Technical term PPPD: the brain holds on to a state of alarm.
During the examination, doctors pay particular attention to jerky eye movements, known as nystagmus. It reveals whether the disorder lies in the organ of balance, in the nerve or in the brain. If no clear cause remains after all the tests, the dizziness is not imagined. The disorder simply does not lie in a single organ that can be specifically tested.
What does your dizziness feel like most?
Balance
Three senses, one calculation
The brain cannot see directly where your body is in space. It calculates this from three sources.
Inner ear
The organ of balance lies next to the cochlea. Three semicircular canals register rotations, and two small organs with crystals register tilt and acceleration. Together, they provide the position of the head relative to gravity.
Neck
Stretch sensors in the muscles and joints of the upper cervical spine report how the head sits on the trunk.
Eyes
The horizon, vertical edges and the surroundings passing by while walking show where the world lies relative to your gaze.
Like a satnav with three positioning sources
Imagine a satnav that determines its position from satellite, wheel sensor and compass. If they all agree, it calmly shows the road. If one source delivers wrong values, the arrow jumps. Balance works in a similar way: dizziness then does not arise from a broken part, but from signals that do not match each other.
How closely the inner ear and neck are combined in this calculation was shown in 2025 by a research group at Johns Hopkins University in Baltimore. In one area of the cerebellum, the majority of nerve cells that responded to balance stimuli also processed signals from the neck. When the researchers changed the position of the head relative to the trunk, the same cells adjusted their response3. The measurements come from rhesus monkeys. The direction is nonetheless clear: head position feeds into the balance calculation.
In our view, dizziness is often a conflict between the senses, not a defect of a single organ.That is why it is not enough to look only at the ear or only at the neck. Balance is a joint effort.
Why does dizziness make you feel sick? According to a hypothesis put forward by Michel Treisman in 1977, the vomiting centre in the brainstem interprets conflicting sensory signals as possible poisoning, because many neurotoxins disrupt exactly this coordination4. In seasickness and in many forms of dizziness, this is a false alarm.
Ménière’s disease
Ménière’s disease: dizziness, ear and hearing during an attack
In Ménière’s disease, balance and hearing come together. The attacks often come without warning and have a strong impact on everyday life.
Since 2015, there have been joint diagnostic criteria from several international professional societies. For a definite diagnosis of Ménière’s disease, there must be repeated attacks of rotational vertigo together with sensorineural hearing loss in the low to middle frequency range. In addition, there are fluctuating complaints in the affected ear: worse hearing, tinnitus or a feeling of pressure and fullness. According to these criteria, an attack lasts between 20 minutes and 12 hours5.
with Ménière’s disease took part in the German BEMED study. For nine months, they received betahistine in two doses or a placebo6
fewer attacks on average were experienced by participants during the observation period, in all three groups. There was no difference between the groups6
The underlying cause is thought to be a build-up of inner ear fluid, endolymphatic hydrops, the origin of which is unclear. The BEMED study shows how difficult the disease is to assess: the attacks also became less frequent without the active substance. According to the authors, the placebo effect, the natural course and fluctuations cannot be separated without an untreated comparison group.
Training the basic functions can be combined with ENT or neurological treatment.
Middle ear
Pressure equalisation and balance
The middle ear and the inner ear lie wall to wall. What happens in the air-filled middle ear does not go unnoticed by the fluid-filled inner ear.
Between the middle ear and the inner ear there are two small openings closed by membranes, the oval window and the round window. Through them, sound and pressure changes reach the inner ear. The middle ear is ventilated via the Eustachian tube, which opens briefly when you swallow. More on this in the article Ear pressure and pressure equalisation.
Swallowing
The soft palate rises, and its muscles pull the Eustachian tube open.
Ventilation
Air equalises the pressure between the nasopharynx and the middle ear.
Windows to the inner ear
The oval and round windows pass pressure differences on to the fluid of the inner ear.
Organ of balance
If the pressure changes unevenly on the two sides, the organ of balance can send signals that do not match the movement.
of 63 experienced recreational divers were familiar with pressure-related dizziness when diving, known as alternobaric vertigo7
of female divers were affected, but only 15 % of male divers. In the authors’ diving clinic, women more often had problems with pressure equalisation7
Alternobaric vertigo occurs when the pressure in the two middle ears changes unevenly. Apart from sex, only one thing distinguished those affected: previous problems with pressure equalisation. So an unevenly ventilated middle ear can disturb balance.
The Eustachian tube has also been studied in Ménière’s disease. In Malmö, a research group measured the pressure directly in the middle ear. 15 of 21 people with active Ménière’s disease were unable to equalise an artificially created overpressure or negative pressure by swallowing, whereas all 20 healthy people could8. The authors consider it possible that such pressure deviations influence the inner ear fluid and thus the symptoms.
In favour
In Tokyo, one in four people examined with Ménière’s disease had an impaired Eustachian tube, and hearing was related to its measured values9.
Against
In an older American analysis of 341 cases, an impaired Eustachian tube was no more common than in sensorineural hearing loss from other causes10.
Pressure from outside
Devices that deliver pressure pulses into the middle ear via a grommet showed no proven benefit in a Cochrane review of five studies; hearing was slightly worse with the device11.
This is not proof that poor ventilation triggers Ménière’s attacks. The findings do show, however, that the middle ear and balance are connected and that functioning pressure equalisation is no minor matter. In our view, the lever does not lie in feeding in pressure from outside. It lies in the body ventilating its middle ear itself, with many hundreds to a thousand swallows a day.
Neck and head balance
The neck as a sense of balance
The small muscles between the back of the head and the upper cervical spine do not just hold the head. They continuously measure how it is positioned.
per gram of muscle are found in the obliquus capitis inferior below the back of the head. Muscle spindles are built-in length gauges12
per gram are found in the large trapezius muscle, which you can feel when your neck is tense12
These short, deep neck muscles are sensors, not powerhouses. Their signals converge in the brainstem with those of the organ of balance.
If the head drifts forwards permanently, for example at the screen, they constantly have to do holding work. In our view, this shifts the zero point from which they measure. The inner ear and neck then report different things, and the brain has to keep recalculating.
The head moves forward
At the screen, on the phone, and in many people since childhood together with mouth breathing.
The neck muscles hold permanently
The small muscles below the back of the head work against the weight of the head.
The measuring point shifts
Their signals no longer match those from the inner ear.
The brain recalculates
As long as the reserve is sufficient, you notice little. Under stress or with an infection, it tips over.
Dizziness and unsteadiness
Light-headedness when getting up, unsteadiness in the dark, a wobbly feeling when walking.
Specialists speak of cervicogenic dizziness. It has been described, but is controversial as a condition in its own right because uniform criteria are lacking. A review from Antwerp evaluated 13 studies with 898 people affected. Manual therapy reduced dizziness, neck and balance complaints with moderate-certainty evidence, and even more when combined with exercises, though here with very low-certainty evidence13. You can read more about the neck in the article Neck and back.
The chain is our model, not a finding for the individual case. If dizziness persists without a finding in the inner ear, in our view the cause usually does not lie in the neck alone, but in the interplay of breathing, swallowing and head balance.
The triad
Breathing, swallowing and head balance: an interplay
Dizziness rarely comes alone. Many people affected also experience tinnitus, ear pressure, neck or jaw complaints.
These complaints are often treated separately, at the ENT practice, in neurology, in physiotherapy or at the dentist. In our view, many of them share a common starting point: the interplay of breathing, swallowing and head balance.
The graphic from our model shows how closely the neck, mouth and throat, nose and nervous system are interlinked. In it, dizziness sits alongside tinnitus, the jaw joint and the neck.
Breathing
With nasal breathing and closed lips, air flows through the nasopharynx, where the Eustachian tube opens. With mouth breathing, the tongue drops and the head often drifts forwards.
Swallowing
A correct swallow from the tongue reference position with brief tooth contact lifts the soft palate firmly and gives the Eustachian tube the opportunity to open.
Head balance
When the head is balanced above the spine, the neck muscles work as sensors rather than as permanent holders, and the inner ear and neck report matching signals.
These functions also lie close together in the brainstem. In rats, nerve cells of the vestibular nuclei project directly into a relay nucleus that helps control breathing, heartbeat and blood pressure14. Changing one function changes the others along with it. That is why we train them together.
More on this in the articles on the tongue reference position, on swallowing and on the vagus nerve.
Treatments
What medicine offers
There are effective treatments for many forms of dizziness. What is striking is how well active methods perform.
of those treated were free of symptoms after the Epley manoeuvre for positional vertigo, compared with 21 % after sham treatment, in five studies with 273 people15
was the relapse rate after treatment according to the same Cochrane review15
In the Epley manoeuvre, the head is positioned in a fixed sequence so that the stray crystals leave the semicircular canal again. The relapse rate also shows, however, that the manoeuvre clears the crystals away. It does not answer why they come loose.
On balance training, known as vestibular rehabilitation, there is a Cochrane review of 39 studies and 2,441 people with a unilaterally impaired organ of balance. The exercises reduced dizziness considerably compared with no treatment, and no side effects were reported16. The brain can relearn a disturbed balance calculation when it is challenged.
Dampening the symptom
- Medication for dizziness and nausea in the acute phase
- Circulation-promoting or herbal remedies
- Medication to prevent Ménière’s attacks
Training the function
- Repositioning manoeuvres for positional vertigo
- Balance training after loss of an organ of balance
- Actively including the neck and head balance
- Practising breathing, swallowing and head balance as a joint pattern
Medicines against dizziness and nausea, above all antihistamines and anticholinergics, dampen the symptom and are intended for the acute phase. They do not change the cause, and they can delay the brain’s compensation instead of promoting it17. That is why they are not a permanent companion. For many forms, balance training is the route that the brain learns itself. Do not stop prescribed medication on your own in the process.
These studies do not examine the FaceFormer. They do, however, show the principle on which our approach is also based: balance is capable of learning, and precisely repeated training changes it. We place our own studies in context on the page Studies and science.
Training
Training head balance and swallowing
Our approach starts where breathing, swallowing and head balance come together, rather than with a single symptom.
In our view, the training addresses the mechanisms that control ventilation and pressure equalisation of the middle ear: swallowing, soft palate, nasal breathing and head balance. If you follow this logic, it can create the conditions under which dizziness and ear pressure can improve, provided they are connected with this interplay. You have to keep at it, and it can be worth it.
In FaceFormer training, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. In the basic exercise, you hold it with your lips, your tongue rests in its reference position on the palate, you breathe through your nose, bite down briefly and swallow. In this way you practise nasal breathing, a strong swallow in which the soft palate rises, and an upright head balance in one sequence.
The film shows the head balance rotation from module 8. It is added to the basic training, supplemented with breathing in module 9, ideally in consultation with a practice.
Slow rather than far
Turn your head evenly and without momentum. If you feel dizzy while turning, turn more slowly and less far. If the feeling persists, stop the exercise.
Not during an attack
Do not train during an acute dizzy spell or Ménière’s attack. Resume once it has subsided.
Discuss pressure exercises first
The AirFlip from module 11 works with pressure changes in the throat. If you have Ménière’s disease, have had sudden hearing loss or have grommets, discuss it with your ENT practice beforehand.
- From day 1
Basic exercise
Three times a day for a few minutes with the FaceFormer ZERO, guided by the free app.
- From around week 3
Pull exercise and night
The pull exercise is added. At night you wear the ZERO once you have mastered the basic exercise.
- After a few weeks
Switching to the ONE
During the day, you train with the FaceFormer ONE. It is the same size and shape as the ZERO, just made of firmer material.
- Once the basic training is established
Head balance rotation
Module 8 is added, later module 9 with breathing.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months until the new sequences run without thinking.
The training does not replace having your dizziness assessed. If you are prone to dizziness, practise sitting down at first. You can find all modules on the exercise pages, and more on the process and duration of the therapy on its own page.
Questions
Frequently asked
What can trigger dizziness?
Loose crystals in the organ of balance, inflammation of the vestibular nerve, Ménière’s disease, circulatory disorders, migraine, low blood pressure, medication or a persistent conflict between the inner ear, neck and eyes. Which form is present is clarified by a medical examination. In our view, with unexplained dizziness it is worth looking at the middle ear, neck and head balance.
When is dizziness dangerous?
When it comes on suddenly and warning signs are added: paralysis or numbness on one side of the body, a drooping corner of the mouth, speech or vision problems, a severe headache, inability to stand or walk, chest pain or impaired consciousness. Then call the emergency number 112 without hesitation. Suddenly worse hearing in one ear should be seen by an ENT practice the same day.
What is Ménière’s disease?
A disorder of the inner ear with recurring attacks of rotational vertigo lasting 20 minutes to 12 hours. These are accompanied in one ear by fluctuating hearing, tinnitus and a feeling of pressure. The underlying cause is thought to be a build-up of inner ear fluid, the origin of which is unclear. The diagnosis is made by an ENT practice.
Can dizziness come from the neck?
The deep neck muscles are densely packed with sensors, and their signals feed into the balance calculation. This is referred to as cervicogenic dizziness, which has been described but is not uniformly defined. Other causes should be ruled out first.
Do medicines help against dizziness?
They dampen dizziness and nausea and are intended for the acute phase. They do not change the cause. Medicines that dampen the balance organ, above all antihistamines and anticholinergics, can also delay the brain’s adaptation. That is why they are not a permanent companion. In the long run, the brain learns through training to readjust a disturbed balance calculation.
Which exercises help with dizziness?
That depends on the form: repositioning manoeuvres for positional vertigo, balance training after loss of an organ of balance, both following a medical diagnosis. In FaceFormer training, you practise breathing, swallowing and head balance in one sequence, together with the head balance rotation from module 8. How quickly anything changes varies.
Can I do FaceFormer training if I have Ménière’s disease?
Training the basic functions can be combined with ENT treatment. During an attack, you pause. Discuss the AirFlip from module 11, which works with pressure changes, with your ENT practice beforehand. Do not stop prescribed medication on your own.
More articles from the knowledge section
Where to go next
Sources
- Neuhauser HK, Radtke A, von Brevern M, Lezius F, Feldmann M, Lempert T (2008). Burden of dizziness and vertigo in the community. Archives of Internal Medicine 168(19):2118-2124. PMID 18955641. Source
- Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB (2006). Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 37(10):2484-2487. PMID 16946161. Source
- Mildren RL, Gómez LJ, Cullen KE (2025). Convergence of vestibular and proprioceptive signals in the cerebellar nodulus/uvula enhances the encoding of self-motion in primates. Current Biology 35(3):468-482.e3. PMID 39793564. Source
- Treisman M (1977). Motion sickness: an evolutionary hypothesis. Science 197(4302):493-495. PMID 301659. Source
- Lopez-Escamez JA, Carey J, Chung WH, Goebel JA, Magnusson M, Mandalà M, Newman-Toker DE, Strupp M, Suzuki M, Trabalzini F, Bisdorff A (2015). Diagnostic criteria for Menière’s disease. Journal of Vestibular Research 25(1):1-7. PMID 25882471. Source
- Adrion C, Fischer CS, Wagner J, Gürkov R, Mansmann U, Strupp M; BEMED Study Group (2016). Efficacy and safety of betahistine treatment in patients with Meniere’s disease: primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial). BMJ 352:h6816. PMID 26797774. Source
- Klingmann C, Knauth M, Praetorius M, Plinkert PK (2006). Alternobaric vertigo: really a hazard? Otology and Neurotology 27(8):1120-1125. PMID 17130801. Source
- Brattmo M, Tideholm B, Carlborg B (2012). Inadequate opening capacity of the eustachian tube in Meniere’s disease. Acta Oto-Laryngologica 132(3):255-260. PMID 22201512. Source
- Kitajima N, Watanabe Y, Suzuki M (2011). Eustachian tube function in patients with Meniere’s disease. Auris Nasus Larynx 38(2):215-219. PMID 21036498. Source
- Forquer BD, Brackmann DE (1980). Eustachian tube dysfunction and Meniere’s disease: a report of 341 cases. American Journal of Otology 1(3):160-162. PMID 7457579. Source
- van Sonsbeek S, Pullens B, van Benthem PP (2015). Positive pressure therapy for Ménière’s disease or syndrome. Cochrane Database of Systematic Reviews 2015(3):CD008419. PMID 25756795. Source
- Sung YH (2022). Suboccipital Muscles, Forward Head Posture, and Cervicogenic Dizziness. Medicina (Kaunas) 58(12):1791. PMID 36556992. Source
- De Vestel C, Vereeck L, Reid SA, Van Rompaey V, Lemmens J, De Hertogh W (2022). Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness. Journal of Manual and Manipulative Therapy 30(5):273-283. PMID 35383538. Source
- Gagliuso AH, Chapman EK, Martinelli GP, Holstein GR (2019). Vestibular neurons with direct projections to the solitary nucleus in the rat. Journal of Neurophysiology 122(2):512-524. PMID 31166818. Source
- Hilton MP, Pinder DK (2014). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews 2014(12):CD003162. PMID 25485940. Source
- McDonnell MN, Hillier SL (2015). Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews 1:CD005397. PMID 25581507. Source
- Rascol O, Hain TC, Brefel C, Benazet M, Clanet M, Montastruc JL (1995). Antivertigo medications and drug-induced vertigo. A pharmacological review. Drugs 50(5):777-791. PMID 8586026. Source
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The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
