Bilateral vestibular hypofunction (BVH) probably represents a heterogeneous disorder with different types of clinical pictures, with and without vertigo. In spite of increasingly sophisticated electrophysiological testing, still many challenges are met when establishing a diagnosis of BVH. Here, we review the main challenges, which are a reflection of its often difficult clinical presentation and the lack of diagnostic standards regarding the implementation and interpretation of vestibular tests. These challenges show that there is an urgent need for standardization. The resulting decisions should be used for the development of uniform diagnostic criteria for BVH, which are, at present, not yet available.