Benign Paroxysmal Positional Vertigo (BPPV) is a common cause of dizziness, accounting for 1 in 5 of all cases of dizziness, and more than half of all cases of dizziness in the elderly.
Correct diagnosis is important, because this disorder can usually be easily corrected in a doctor’s office.
BPPV is caused by debris which has collected in in the inner ear, resulting in multiple recurrent short episodes of dizziness or vertigo, imbalance, and nausea provoked by specific head movements.
Because most cases of BPPV are from debris in the posterior semicircular canals, symptoms are generally provoked by rolling over in bed, looking up (“top shelf vertigo”), getting a hair wash, yoga positions etc.
The diagnosis of BPPV can be suggested by history, but is confirmed by a provocative test such as the Hallpike-Dix maneuver. In this test, a person is brought from sitting to a supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward. A positive Hallpike-Dix test consists of a self-limited episode of vertigo accompanied by abnormal eye movements (nystagmus) that comes on after a short latency period. The symptoms will often recur when the patient is brought back up to the sitting position, but after that will quickly fatigue.
Untreated, symptoms of BPPV can persist for a few weeks or months, then stop spontaneously, but will often come back again. Affected patients will try to avoid provoking dizziness by sleeping with two or more pillows at night, not sleeping on the “bad” side, and modifying their daily activities so as to avoid head positions that exacerbate symptoms.
The Epley can be very effective, with an 80% cure rate, particularly when followed by the these precautions to reduce the chance that debris might fall back into the sensitive back part of the ear:
1. Have the patient sleep semi-recumbent for the next 2 nights in a recliner chair
2. Encourage them to avoid tilting the head backwards for the next 2-3 days – do not go to the hairdresser or dentist, avoid putting the head back for shaving, accessing the top shelf or putting in contact lenses etc. It is sometimes helpful to have the patient wear a soft cervical collar to remind them of this restriction.
3. If the symptoms recur when normal activity is resumed, the patient should undergo at least one further trial of the Epley maneuver.
If the patient cannot get to a doctor familiar with the Epley, they can try a home exercise such as the Brandt-Daroff exercises. These exercises take longer to work, but many patients get significant relief of their symptoms within 7-10 days.
If the patient has persistent symptoms despite multiple attempts at the Epley and/or Brandt-Daroff exercise, one should first consider an alternate explanation for paroxysmal vertigo such as basilar migraine, acoustic neuroma, “Tournado” epilepsy or Meniere’s disease. However, if the diagnosis of BPPV seems secure, and symptoms are truly recalcitrant, there are surgical options such as posterior canal plugging.