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Benign Paroxysmal Positional Vertigo

(Benign Postural Vertigo; Benign Positional Vertigo; BPPV)

By Lawrence R. Lustig, MD

Benign paroxysmal positional vertigo, or BPPV, is a common disorder causing short episodes of vertigo (a false sensation of moving or spinning) in response to changes in head position that stimulate the posterior semicircular canal of the inner ear.

  • People briefly (usually for less than a minute) feel as if they or their surroundings are moving or spinning when they move their head.

  • People may also feel nauseated and vomit, and their eyes may move abnormally.

  • Doctors base the diagnosis on symptoms and the situations in which they occur and a physical examination.

  • The Epley maneuver, done once or twice, relieves symptoms in most people.

People with vertigo have a false sensation that they, their surroundings, or both are moving or spinning. Most people describe this unpleasant feeling as "dizziness," although people often also use the word "dizzy" for other sensations, such as being light-headed. "Positional" vertigo means that the vertigo comes when people change position, for example, laying down in bed and turning their head. "Benign" means that the disorder is not dangerous.

BPPV affects people increasingly as they age and can severely affect balance in older people, which may lead to falls and possibly injuries.


A change in head position—typically turning the head over on the pillow on first awakening in the morning or tipping the head backward to reach a high shelf—triggers most episodes of this disorder. BPPV usually develops when calcium particles (otoconia) that are normally embedded in one part of the inner ear (the utricle and saccule) are displaced and move into another part of the inner ear (most commonly the posterior semicircular canal).

The inner ear contains three semicircular canals, which help with balance (see Figure: A Look Inside the Ear). The posterior canal, unlike the superior canal (also called the anterior canal) and the lateral canal, is in the best position to receive most of the loose particles through gravity during the night. As they collect, they form a chalky sludge that exaggerates the movement of fluid in the canal when the head changes position. The result is overstimulation of nerve receptors (hair cells) inside the posterior canal, creating a false sensation of moving or spinning.

Particles may be displaced from the utricle and saccule as people age. Or, displacement may be caused by

  • Ear infections

  • Head or ear injury

  • Prolonged bed rest

  • Ear surgery

  • Other inner ear disorders (such as Meniere disease)

  • Possible blockage of an artery to the inner ear


The symptoms of benign positional vertigo are

  • Short episodes of vertigo, in which people feel as if they or their surroundings are moving or spinning

  • Nausea and/or vomiting

Benign positional vertigo can be frightening and uncomfortable, but it is usually harmless and disappears by itself.

Vertigo is triggered when the person’s head moves, such as when rolling over in bed or bending over to pick up something. Each episode of vertigo lasts only a few seconds to minutes. People may have many episodes over the course of a few days to weeks after which episodes gradually subside on their own. Vertigo may be accompanied by nausea, vomiting, and a specific type of nystagmus (the rapid jerking movement of the eyes in one direction alternating with a slower drift back to the original position). No hearing loss or noise in the ears (tinnitus) occurs.

Although the symptoms are not dangerous, they may lead to falls or other accidents if an episode occurs while a person is in a possibly unsafe situation such as driving a car.


  • Dix-Hallpike maneuver

  • Sometimes imaging tests

Diagnosis is based on a description of the symptoms and the circumstances in which they occur.

Usually, the test used is theDix-Hallpike maneuver, which helps move the particles from a part of the ear where they are causing the vertigo to a part of the ear where they are harmless. The person sits on the examining table with the head turned 45 degrees to the right. Then the person lies down backwards so that the head remains turned at 45 degrees and hangs over the examining table by about 20 degrees. In BPPV, there is a delay of about 5 to 10 seconds before vertigo and nystagmus occur (called latency), but the delay may be as long as 30 seconds. Symptoms last 10 to 30 seconds then decrease and disappear (called fatigue). Maintaining the gaze on a single location (visual fixation) can shorten or even abolish nystagmus, so the maneuver is ideally done with the person wearing Frenzel lenses (which make it impossible to visually fixate on anything). If the maneuver is repeated several times, the intensity of the vertigo and nystagmus decreases (called habituation) in people who have BPPV. However, in people who have vertigo due to a brain disorder (such as stroke or multiple sclerosis), which is more serious, the Dix-Hallpike maneuver triggers symptoms immediately, the vertigo persists as long as the head is held in the same position, and habituation does not occur when the maneuver is repeated.

Sometimes imaging tests (such as gadolinium-enhanced magnetic resonance imaging) are done when doctors are not sure whether the vertigo is being caused by another, possibly dangerous, disorder.


  • Head maneuvers to reposition particles in the ear canal

  • Drug treatment is not typically recommended

BPPV is easily treated. The particles simply need to be moved out of the posterior semicircular canal and into a part of the ear where they do not cause symptoms. Doing so requires a somersault-like maneuver of the head, called a canalith repositioning maneuver, such as the Epley maneuver. This maneuver immediately improves vertigo in about 90% of people. Repeating the maneuver may help a few additional people. In some people, the vertigo recurs. If it does, the maneuver is repeated. People can be taught how to do the maneuver at home in case vertigo recurs. Although the posterior semicircular canal is most commonly affected by BPPV, occasionally the lateral canal is affected, and people can roll themselves like a log to relieve the symptoms.

Doctors may prescribe vestibular suppressant drugs, including meclizine or a benzodiazepine (such as diazepam or lorazepam), for short-term relief, but these drugs are ineffective for long-term use and may worsen symptoms.

If the repositioning maneuvers do not work, doctors usually look for other, more serious, disorders that may be the cause of symptoms.

Very rarely, surgery is needed.

The Epley Maneuver: A Simple Cure for a Common Cause of Vertigo

Some people experience vertigo when they change the position of their head rapidly, as when rolling their head on the pillow, looking down to tie their shoes, or looking up to reach for an item on a high shelf. This vertigo is usually due to benign paroxysmal positional vertigo (BPPV). It occurs when tiny calcium particles (otoconia) are displaced from their normal location to form sludge, usually in the posterior semicircular canal (one of the canals in the inner ear). The disorder can often be cured by using the Epley maneuver to move the particles out of the canal and back to where they originated. In this maneuver, the person’s body and head are moved into different positions, one after the other. Each position is maintained for about 30 seconds to allow the particles to move by gravity into a different part of the canal. To check if the maneuver worked, the person moves the head in the same way that previously caused vertigo. If vertigo does not occur, the maneuver worked. After performing this maneuver, people should remain upright or semiupright for 1 to 2 days.

The maneuver is done by following the clockwise order of the red arrows below:

Finally, the head and body are turned even more, until the nose points down at the floor. The person then sits up but keeps the head turned to the far left. Once the person is upright, the head can face forward.

First, with the person sitting, the head is turned about 45degrees to the right or left, depending on which side triggers the vertigo. The person then lies down with the head hanging over the edge of the examining table (or bed). The sludge triggers an exaggerated signal to the brain, resulting in vertigo.

The head is turned further to the left, so that the ear is parallel to the floor.

The head is then turned to the other side at the same angle.

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