The Vestibulo-ocular Reflex and Head Impulse Testing

  • Erika McCarty Walsh
  • Dennis I. BojrabEmail author


The major role of the vestibulo-ocular reflex (VOR) is to stabilize the eyes for clear vision during movement in daily life. Periodic head movements during normal life activities move the head at fundamental frequencies of 2–4 Hz, with harmonics extending above these frequencies. The other ocular control systems are relatively insensitive above 2 Hz and therefore the VOR functions as the primary control system for visual stabilization during locomotion. Traditional testing using caloric stimulation of the lateral semicircular canal is limited to a very low-frequency response, and only one canal of the labyrinth is tested. Traditional rotational chair systems test only the lateral semicircular canal and at relatively low-frequency levels. At a constant rotational velocity, the semicircular canals are not stimulated, only with acceleration or deceleration. This chapter is to cover active and passive head movements to test the VOR from 2 to 6 Hz, using the autorotational test and the video head impulse test (vHIT) that simulates more authentic daily VOR challenges.

Eye movements resulting from low-frequency rotational testing are composed of slow and fast phases of nystagmus. The slow phase is directed by VOR, and the fast phase is a result of compensation by the paramedian pontine reticular formation which causes the saccadic eye movements. Linear analysis of the VOR cumulative eye position results in relatively accurate gain and phase because of the apparent linearity of the system. Phase and gain change abnormalities are the basis of the testing paradigm.


Vertigo Vestibular testing Head impulse testing 


  1. 1.
    Beh SC, Frohman TC, Frohman EM. Cerebellar control of eye movements. J Neuroophthalmol. 2017;37(1):87–98. Scholar
  2. 2.
    Furman JM. Rotational testing. Handb Clin Neurol. 2016;137:177–86. Scholar
  3. 3.
    Halmagyi GM, Chen L, MacDougall HG, Weber KP, McGarvie LA, Curthoys IS. The video head impulse test. Front Neurol. 2017;8:258. Scholar
  4. 4.
    Kheradmand A, Zee DS. The bedside examination of the vestibulo-ocular reflex (VOR): an update. Rev Neurol (Paris). 2012;168(10):710–9. Scholar
  5. 5.
    Schubert MC, Hall CD, Das V, Tusa RJ, Herdman SJ. Oculomotor strategies and their effect on reducing gaze position error. Otol Neurotol. 2010;31(2):228–31. Scholar
  6. 6.
    Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol. 1988;45(7):737–9.CrossRefGoogle Scholar
  7. 7.
    Weber KP, Aw ST, Todd MJ, McGarvie LA, Curthoys IS, Halmagyi GM. Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. Neurology. 2008;70(6):454–63. Scholar
  8. 8.
    Barany R. (1876–1936) – investigator of labyrinthine function. JAMA. 1965;191:132–3.Google Scholar
  9. 9.
    Jenkins HA, Honrubia V, Baloh RH. Evaluation of multiple-frequency rotatory testing in patients with peripheral labyrinthine weakness. Am J Otolaryngol. 1982;3(3):182–8.CrossRefGoogle Scholar
  10. 10.
    Harvey SA, Wood DJ, Feroah TR. Relationship of the head impulse test and head-shake nystagmus in reference to caloric testing. Am J Otol. 1997;18(2):207–13.PubMedGoogle Scholar
  11. 11.
    Kessler P, Tomlinson D, Blakeman A, Rutka J, Ranalli P, Wong A. The high-frequency/acceleration head heave test in detecting otolith diseases. Otol Neurotol. 2007;28(7):896–904.CrossRefGoogle Scholar
  12. 12.
    Fineberg R, O’Leary DP, Davis LL. Use of active head movements for computerized vestibular testing. Arch Otolaryngol Head Neck Surg. 1987;113(10):1063–5.CrossRefGoogle Scholar
  13. 13.
    Kitsigianis GA, O’Leary DP, Davis LL. Active head-movement analysis of cisplatin-induced vestibulotoxicity. Otolaryngol Head Neck Surg. 1988;98(1):82–7. Scholar
  14. 14.
    O’Leary DP, Davis LL. Vestibular autorotation testing of Menière’s disease. Otolaryngol Head Neck Surg. 1990;103(1):66–71. Scholar
  15. 15.
    O’Leary DP, Davis LL, Maceri DR. Vestibular autorotation test asymmetry analysis of acoustic neuromas. Otolaryngol Head Neck Surg. 1991;104(1):103–9. Scholar
  16. 16.
    Saadat D, O’Leary DP, Pulec JL, Kitano H. Comparison of vestibular autorotation and caloric testing. Otolaryngol Head Neck Surg. 1995;113(3):215–22. Scholar
  17. 17.
    Macdougall HG, McGarvie LA, Halmagyi GM, Curthoys IS, Weber KP. The video Head Impulse Test (vHIT) detects vertical semicircular canal dysfunction. PLoS One. 2013;8(4):e61488. Scholar
  18. 18.
    Crane BT, Demer JL. Latency of voluntary cancellation of the human vestibulo-ocular reflex during transient yaw rotation. Exp Brain Res. 1999;127(1):67–74.CrossRefGoogle Scholar
  19. 19.
    Shen Q, Magnani C, Sterkers O, et al. Saccadic velocity in the new suppression head impulse test: a new indicator of horizontal vestibular canal paresis and of vestibular compensation. Front Neurol. 2016;7:160. Scholar
  20. 20.
    Tranter-Entwistle I, Dawes P, Darlington CL, Smith PF, Cutfield N. Video head impulse in comparison to caloric testing in unilateral vestibular schwannoma. Acta Otolaryngol (Stockh). 2016;136(11):1110–4. Scholar
  21. 21.
    Palla A, Straumann D. Recovery of the high-acceleration vestibulo-ocular reflex after vestibular neuritis. J Assoc Res Otolaryngol. 2004;5(4):427–35.CrossRefGoogle Scholar
  22. 22.
    Cordero-Yanza JA, Arrieta Vázquez EV, Hernaiz Leonardo JC, Mancera Sánchez J, Hernández Palestina MS, Pérez-Fernández N. Comparative study between the caloric vestibular and the video-head impulse tests in unilateral Menière’s disease. Acta Otolaryngol (Stockh). 2017;137(11):1178–82. Scholar
  23. 23.
    Nguyen KD, Minor LB, Della Santina CC, Carey JP. Vestibular function and vertigo control after intratympanic gentamicin for Ménière’s disease. Audiol Neurootol. 2009;14(6):361–72. Scholar
  24. 24.
    Perez-Fernandez N, Eza-Nuñez P. Normal gain of VOR with refixation saccades in patients with unilateral vestibulopathy. J Int Adv Otol. 2015;11(2):133–7. Scholar
  25. 25.
    Pérez-Fernández N, Gallegos-Constantino V, Barona-Lleo L, Manrique-Huarte R. Clinical and video-assisted examination of the vestibulo-ocular reflex: a comparative study. Acta Otorrinolaringol Esp. 2012;63(6):429–35. Scholar
  26. 26.
    McCaslin DL, Jacobson GP, Bennett ML, Gruenwald JM, Green AP. Predictive properties of the video head impulse test: measures of caloric symmetry and self-report dizziness handicap. Ear Hear. 2014;35(5):e185–91. Scholar
  27. 27.
    Blödow A, Blödow J, Bloching MB, Helbig R, Walther LE. Horizontal VOR function shows frequency dynamics in vestibular schwannoma. Eur Arch Otorhinolaryngol. 2015;272(9):2143–8. Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Neurotology, Providence HospitalMichigan Ear InstituteFarmington HillsUSA

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