White Matter Lesions and Dizziness/Imbalance

white matter disease dizziness imbalance
Brady Workman
February 8, 2026

Let me first start by disclosing that I am not a neurologist. As such, much of what will be discussed here is an overly simplistic explanation of complex neurological processes. The aim is simply to increase awareness of white matter lesions and their associations with dizziness, imbalance, and falls. The most appropriate specialist to address white matter abnormalities is a neurologist.

Dizziness and imbalance can be caused by a myriad of conditions, and in many cases, symptoms are multifactorial. Diagnosis can be challenging, and multi-specialty assessment is often necessary to determine the underlying source(s).

Working in a specialty vestibular clinic, I frequently see patients who have undergone brain MRI, often with reports stating that no acute intracranial abnormality was identified. This is reassuring, as it indicates the absence of stroke, brain tumor, or other serious pathology. However, many of these patients also show signs of white matter disease or lesions.

For some individuals, this information may be clinically relevant, yet in my experience it is sometimes not addressed as a potential contributing factor to dizziness and imbalance.

Understanding White Matter and Clinical Implications

For those unfamiliar, white matter in the brain functions much like wiring in a computer, helping different regions communicate with one another. It appears white due to myelin, the protective coating surrounding nerve fibers. Disruption in communication between brain regions can lead to functional problems. On MRI, these abnormalities appear as hyperintensities, or bright spots.

While hyperintensities have many potential causes, the most common are aging, hypertension, high cholesterol, and diabetes. These findings are quite common on imaging, but when present in greater number or in specific brain regions, symptoms may emerge.

When white matter changes are extensive or affect key brain regions, they may contribute to dizziness, imbalance, and increased fall risk.

There is substantial evidence linking white matter disease with dizziness, imbalance, slower gait speed, gait instability, cognitive impairment, and falls, particularly in individuals with more severe white matter hyperintensities.

Importantly, these patients typically do not experience classic rotary vertigo associated with inner ear disorders. Instead, they often describe a vague, nonspecific sense of dizziness and imbalance. Lesions affecting the frontal lobe and periventricular regions appear most strongly associated with these symptoms. This is logical, as the frontal lobe plays a key role in cognition and voluntary movement, while periventricular pathways serve as major communication routes between the brain and body. Disruption in these areas can contribute to dizziness, imbalance, and falls.

Medical management is guided by the suspected underlying cause of white matter abnormalities. Evidence suggests that controlling high blood pressure may slow progression and, in some cases, lead to regression. Management of high cholesterol with statins and appropriate diabetes care aims to reduce further progression.

In addition, vestibular rehabilitation—a specialized form of physical therapy—has been shown to significantly reduce fall risk.

References

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Brady Workman, AuD

Brady Workman, AuD, is an audiologist in the Balance Disorders program at Wake Forest Baptist Health Center. He has authored several articles relating to balance and vestibular disorders as a regular contributor and co-editor of the Dizziness Depot at Hearing Health & Technology Matters. Brady received his doctorate of audiology from East Tennessee State University in 2018 and is licensed by the North Carolina Board of Examiners for Speech Language Pathologists and Audiologists and is a fellow of the American Academy of Audiology.

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