Dizziness and anxiety after concussion: a shared pathway?

The vestibular system does more than keep us upright

The vestibular apparatus in the inner ear is usually described as a balance organ. Its central connections go much further. A review by Rajagopalan and colleagues sets out how the vestibular nuclei project to structures central to emotional processing:

• The amygdala, which drives threat detection and fear responses
• The hypothalamus, including pathways to the paraventricular nucleus that activate the stress (HPA) axis
• The hippocampus, involved in memory and spatial navigation
• The insula and anterior cingulate cortex, which combine signals from the body into our sense of how we feel
• The dorsal raphe nucleus and locus coeruleus, the brain’s main sources of serotonin and noradrenaline
• The parabrachial nucleus, a brainstem hub linking balance, autonomic function and emotional state

The vestibular system also feeds directly into autonomic control, adjusting heart rate and blood pressure as we change position. Balaban and Thayer described these shared pathways two decades ago as a neurological basis for balance and anxiety links. Put simply, the circuits that tell us where we are in space overlap with the circuits that tell us whether we are safe.

The relationship runs both ways

If those pathways are shared, you would expect vestibular problems and emotional problems to travel together. The clinical data support that.

A 2026 systematic review and meta-analysis in The Laryngoscope (Kim et al., 85 studies, over 760,000 participants) found pooled anxiety prevalence of 31.4% in adults with vestibular disorders against 8.3% in controls. Depression prevalence was 28.3% against 4.7%.

Large cohort data point the same way. A UK Biobank analysis of more than 450,000 people (Chen et al., BMC Medicine) found that people hospitalised with peripheral vertigo had roughly double the risk of subsequent depression and anxiety, with risk highest in the first two years after diagnosis.

The link also works in reverse. Anxiety and low mood measurably change how people control their balance, even in healthy participants (Bolmont et al., 2002). This loop is one way to understand persistent postural-perceptual dizziness (PPPD), where an initial vestibular insult sets off heightened vigilance and altered postural control, and those changes keep the dizziness going long after the original injury has settled.

Where concussion fits

Before going further, it is worth being clear about what is established and what is not. The anatomical connections described above are well documented, as is the fact that vestibular and emotional symptoms frequently co-occur. Whether vestibular disruption after concussion directly drives those emotional symptoms is not settled. The evidence that follows is largely observational, and it shows association rather than cause.

That said, concussion is one of the most common ways an otherwise healthy, active person ends up with vestibular dysfunction and emotional symptoms at the same time.

Vestibular problems after concussion are common, and they track with slower recovery:

• In a youth concussion clinic cohort of 247 patients, 81% showed a vestibular abnormality on initial examination. Those with vestibular deficits took a median of 59 days to return to school, compared with 6 days for those without (Corwin et al., 2015). This was a specialist referral population, so the prevalence is higher than in concussion overall, but the difference in recovery time is striking.
• In high school footballers, dizziness at the time of injury was the only on-field sign that predicted protracted recovery, with an odds ratio of 6.34 for recovery taking 21 days or longer (Lau et al., 2011).

There is evidence of measurable injury behind these symptoms in athletes. Gard and colleagues (2022) found that post-concussive vestibular dysfunction was related to injury of the inferior vestibular nerve, and the same group later identified widespread white matter abnormalities in concussed athletes using 7T diffusion MRI. Depressive and anxiety symptoms after concussion have themselves been linked to white matter changes and specific qEEG patterns, which points to a biological basis rather than a purely psychological reaction to being injured.

Mental health problems after mTBI are also more common than many people expect. In the US TRACK-TBI study of 1,155 patients seen in emergency departments, 21.2% reported PTSD and/or major depression six months after mild TBI, compared with 12.1% of patients with orthopaedic injuries (Stein et al., 2019). Markers of injury severity, such as loss of consciousness, did not predict who developed these problems. A “mild” injury is not always mild in its effects.

A recent scoping review of adult athletes with persisting symptoms after concussion (Lumb et al., 2026), a term now preferred over post-concussion syndrome because it frames the symptoms as injury-related and treatable, found that most of the included studies reported a link between persisting symptoms and symptoms of depression or anxiety. Persisting symptoms are thought to affect roughly 10% to 35% of athletes, depending on the cohort and how “persisting” is defined.

The relationship also runs in the other direction before any injury occurs. Athletes with pre-existing depressive and anxiety symptoms are more than twice as likely to go on to sustain a concussion (Thomas et al., 2024). Emotional symptoms are a risk factor to screen for, not only an outcome to monitor afterwards.

It is worth noting that not all of this is neurobiology. Sport-related concussion carries pressures that other head injuries do not: expectations to return to play, stigma around head injury, fear of re-injury, and the gap between how an athlete saw themselves before the injury and how they feel now. That gap alone has been associated with depressive symptoms and apathy.

What this means in clinic

Symptoms overlap, so assess both domains. Dizziness, light-headedness, a racing heart, poor concentration and feeling “foggy” appear on concussion symptom scales, and they are also features of anxiety. A symptom score on its own cannot tell you which is driving what. Objective vestibular and oculomotor assessment alongside structured mental health screening gives a clearer picture than either alone.

A concussion symptom scale is not a mental health screen. This is one of the clearest messages from the Lumb review. Across the studies included, positive associations between persisting symptoms and depression or anxiety were found most often where dedicated psychological screening had been used. Studies that relied on the emotional items embedded within a general concussion symptom scale were more likely to report inconclusive or negative associations. The emotional questions on a symptom scale flag that something is wrong. They are not built to characterise it.

The same review identified the flip side of that problem. Across just 14 studies, 13 different screening instruments were used, and most were generic tools not developed for athletes. That inconsistency limits what research can tell us and leaves clinicians without a clear pathway. It is precisely the gap the IOC set out to close with a sport-specific, standardised tool (more on that below).

Watch for avoidance. Athletes who feel dizzy in busy or visually complex environments often start avoiding them. That is understandable, but avoidance can reinforce both vestibular sensitivity and anxiety. Graded exposure is a core principle of vestibular rehabilitation, and it overlaps with approaches used in psychological therapy.

Don’t assume the exercise protocol covers it. Several studies in the Lumb review found that structured exercise improved physical symptoms but did not significantly reduce depression or anxiety symptoms. Graded return to activity is well supported for concussion recovery, but emotional symptoms appear to need their own targeted input rather than resolving alongside the physical ones.

Screen early and routinely, not only when recovery stalls. The review argues that psychological screening and management should be an integral part of concussion care rather than something triggered when symptoms fail to settle. The vestibular cohort data point the same way, with the highest risk window for anxiety and depression falling soon after onset.

The standardised option for athletes: SMHAT-2

For clinicians working in sport, the IOC has updated its athlete mental health screening tool. The IOC Sport Mental Health Assessment Tool 2 (SMHAT-2), developed by Gouttebarge and colleagues, was created specifically to address the feasibility, reliability and validity gaps identified in SMHAT-1. It uses a three-step approach:

1. Mandatory screening with disorder-specific questionnaires and two single-item questions
2. Conditional screening, triggered by the results of Step 1
3. Clinical assessment by a sports medicine physician or licensed mental health professional, to guide treatment planning

It is designed for athletes aged 16 and over and covers areas including anxiety, depression, substance use and disordered eating. Two features make it the sensible default for this population. It was built for athletes rather than borrowed from general practice, and it is a stepped pathway rather than a single questionnaire, so a positive screen leads somewhere specific rather than leaving a clinician holding a score.

SMHAT-2 is now available free on ScreenIT, alongside SCAT6 and the vestibular assessments, so mental health and vestibular findings sit on the same athlete timeline and can be tracked across a recovery.

What we don’t yet know

Much of the anatomical evidence for vestibular and limbic connections comes from animal tracing studies, and the human data are largely observational. In the athlete literature specifically, almost all the evidence is cross-sectional, only one of the 14 studies in the Lumb review was rated high confidence, and time since injury across those studies ranged from 28 days to 55 years. Depression and anxiety were also nearly always assessed together, so we cannot yet say which predominates after concussion. Vestibular stimulation as a direct treatment for mood is an interesting idea, but the evidence is early. The shared pathways are well described. How best to use that knowledge clinically is still being worked out.

Hearing the whole story

This year’s World Mental Health Day theme is Lived Experiences Heard: Real Voices, Real Change. After a concussion, part of listening well is recognising that “I feel dizzy” and “I feel anxious” may be two descriptions of the same experience. The brain does not keep balance and emotion in separate boxes, and our assessments should not either.