Benign Paroxysmal Positional Vertigo

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.

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BPPV can be caused by head trauma, vestibular neuronitis, or posterior head positioning during dental work, hair washing or neck manipulation, but can also occur spontaneously.

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.

The nystagmus can be made more obvious by removing visual fixation using Frenzel lenses:

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.

However, once correctly diagnosed, BPPV can be readily treated by simple maneuvers that can be performed in a doctor’s office, such as the Epley maneuver:

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
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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.

Download Brandt-Daroff Exercise Instructions Here

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.

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6 thoughts on “Benign Paroxysmal Positional Vertigo

  1. Hi Dr Holland – I am a 30 yr old female that had a concussion 2 years ago and suffer from severe post concussion syndrome. My prominent symptoms are: vertigo/dizziness, endless headaches, strong pressure/tenseness feeling in the head between the eyes, fogginess, ‘out-of-it’ feeling, and slight short term recollection issues. The biggest triggers are, computer screens, scrolling motion on screens, florescent lights, and busy places like shopping malls. I have had one neurologist say that the type of vertigo induced by concussions usually can’t be cured by the Epley Maneuver; whereas another neurologist has recommended it. I would be very appreciative to hear your thoughts. Thank you.

    • The Epley is only curative for BPPV. Having said that, BPPV is caused by head trauma, so some patients with “concussion” actually have BPPV. You would need a careful neurologic exam including Halpike-Dix (positional) testing to know for sure.

  2. Hello, I woke up in the middle with my earplugs on and fell back into bed. I then started having a SEVERE attack of vertigo with eye shuttering where the room was spinning and I was vomiting. (I wonder if the earplugs caused this by ear pressure). I went to the doctor that morning where he performed the Epley Manuever. It has been two weeks since this time and I am still getting dizzy when laying down and getting up from a laying position, and sometimes when just standing. I am grateful that I can work and function, but am wondering if I should do the Epley again to clear the dizzyness or will it make it worse. Also, have you heard of the half somersault manuever? I’m also confused as to what side I should do these types of manuevers on since I can’t tell which side is affected more now. Please help. My doctor has not been helpful.

    • Thanks for your comment Marie. It sounds as if you still have BPPV – sometimes the first Epley doesn’t “take”. You should either go back to your (or another) doctor to get re-evaluated and try the Epley again, or do the Brandt-Daroff exercises on your own.

  3. Comment from contact form:

    My mother 59 years old is suffering from BPPV since the last 6 years and has been taking Vertin 8 for the same.

    Due to the longstanding illness, she has developed a lot of fear and anxiety in anticipation of the next vertigo attack and is also petrified to go in for the Epley maneuverer or brandt daroff exercises.

    However she has been taking precaution in terms of lying down on the non-affected side, keeping 2 pillows, not turning or jerking her head / neck towards the affected side. Inspite of which she had a slight bought of vertigo yesterday.

    Just wanted to know if it this is likely to happen inspite of following all precautions. What else can we do to completely eliminate another recurrence of bppv ?

    Thanks, savita

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