Visual Vertigo Analogue Scale (VVAS)

Overview

The Visual Vertigo Analogue Scale (VVAS) is a brief self-report questionnaire that measures how much dizziness or unsteadiness is provoked by everyday situations involving movement, visual complexity, or busy visual environments — supermarket aisles, traffic, crowds, patterned floors, and similar scenes. It is designed to capture visual vertigo (also called visually induced dizziness, or visual dependence): a heightened reliance on visual input for balance that causes symptoms when that visual input is complex, moving, or conflicting with other balance signals.

Unlike tools that measure overall dizziness handicap, the VVAS isolates one specific — and clinically important — trigger pattern, which helps identify patients who are likely to benefit from optokinetic and visual desensitisation exercises as part of vestibular rehabilitation.

History

Visual vertigo as a clinical concept was described by Michael Guerraz, Lucy Yardley, and colleagues, who published foundational work on symptom assessment, spatial orientation, and postural control in visual vertigo in Brain in 2001, establishing that a subset of patients with vestibular disorders experience disproportionate symptoms in visually complex or moving environments. Building on this, Elizabeth Dannenbaum, Gevorg Chilingaryan, and Joyce Fung developed and validated the visual analogue scale format widely used today, publishing their assessment questionnaire in the Journal of Vestibular Research in 2011.

The VVAS format — a series of everyday visually provocative situations, each rated on a 0–100 analogue scale — was designed to be quick to administer while giving clinicians a reliable, quantifiable way to identify and monitor visual dependence, complementing existing vestibular and dizziness handicap measures rather than replacing them.

Indications

The VVAS is used wherever visually provoked dizziness or unsteadiness is a relevant clinical feature:

• Persistent postural-perceptual dizziness (PPPD), where visual vertigo is a core diagnostic feature and often the most functionally limiting symptom.
• Vestibular migraine, where visual motion sensitivity is a common and often prominent trigger.
• Post-concussion and mild traumatic brain injury, where visually provoked dizziness frequently persists after other symptoms have settled.
• Peripheral vestibular disorders in the compensation phase, to identify patients who have developed secondary visual dependence during recovery.
• Planning vestibular rehabilitation, particularly to guide the use of optokinetic stimulation and habituation exercises targeting specific visually provocative environments.
• Monitoring treatment response to vestibular rehabilitation aimed at reducing visual dependence, through repeated administration over a course of care.

How It’s Scored

Each of the 9 situations is rated on a 0 (no dizziness) to 100 (severe dizziness) analogue scale, most often presented as a 100mm line and, as in this interactive tool, frequently simplified to 10-point increments for ease of completion. The total score is calculated as the average of all 9 item ratings, giving an overall score between 0 and 100 — higher scores indicate greater visually provoked dizziness or unsteadiness.

Interpreting the score

The VVAS doesn’t have a single, universally agreed severity banding the way some shorter symptom scales do. Validation work has consistently found that people with visual vertigo — particularly those with PPPD or vestibular migraine — score substantially higher, on average, than people without vestibular symptoms or with vestibular disorders that don’t involve visual dependence. In clinical use, the VVAS is most valuable as a way to confirm the presence of a visually provoked symptom pattern and to track whether that pattern is improving over a course of treatment, rather than as a single number read against a fixed cut-off.

What It Tells the Clinician

• Identifies visual dependence as a specific driver of symptoms. A high VVAS score in a patient whose vestibular test battery is otherwise unremarkable can point toward PPPD or a significant visual-vestibular mismatch component to their presentation.
• Guides rehabilitation targeting. Item-level responses highlight exactly which visual environments provoke the most symptoms — supermarkets, traffic, crowds — which can directly shape which optokinetic and habituation exercises are prioritised.
• Complements handicap and confidence measures. Used alongside tools like the DHI or ABC Scale, the VVAS adds a specific mechanistic dimension — not just how handicapped or unconfident a patient feels, but which category of trigger is driving it.
• Supports differential diagnosis. A disproportionately high VVAS relative to otherwise mild vestibular findings is a recognised pattern in PPPD and vestibular migraine, and can help distinguish these functional and central presentations from purely peripheral vestibular disorders.
• Tracks desensitisation over the course of rehabilitation. Because it targets a specific, modifiable symptom trigger, the VVAS is well suited to demonstrating measurable progress as visual desensitisation therapy proceeds.

References

1. Dannenbaum E, Chilingaryan G, Fung J. Visual vertigo analog scale: an assessment questionnaire for visual vertigo. J Vestib Res. 2011;21(3):153-159.
2. Guerraz M, Yardley L, Bertholon P, et al. Visual vertigo: symptom assessment, spatial orientation and postural control. Brain. 2001;124(Pt 8):1646-1656.