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Benign Paroxysmal Positional Vertigo

(Benign Positional Vertigo; Benign Postural Vertigo; BPPV)


Mickie Hamiter

, MD, New York Presbyterian Columbia

Reviewed/Revised May 2023
Topic Resources

In benign paroxysmal positional vertigo, short (< 60 seconds) episodes of vertigo occur with certain head positions. Nausea and nystagmus develop. Diagnosis is clinical. Treatment involves canalith repositioning maneuvers. Medications and surgery are rarely, if ever, indicated.

Benign paroxysmal positional vertigo (BPPV) is the most common cause of relapsing otogenic vertigo. It affects people increasingly as they age and can severely affect balance in older adults, leading to potentially injurious falls.

Etiology of Benign Paroxysmal Positional Vertigo

BPPV is thought to be caused by displacement of otoconial crystals (calcium carbonate crystals normally embedded in the saccule and utricle). This displaced material stimulates hair cells most commonly in the posterior semicircular canal, occasionally in the lateral semicircular canal, and rarely in the superior semicircular canal, creating the illusion of motion. Etiologic factors include

Inside the Ear

Inside the Ear

Symptoms and Signs of Benign Paroxysmal Positional Vertigo

Vertigo is triggered when the patient’s head moves (eg, when rolling over in bed or bending over to pick up something). Acute paroxysms of vertigo last only a few seconds to minutes; episodes tend to peak in the morning and abate throughout the day. Nausea and vomiting may occur, but hearing loss and tinnitus do not.

Diagnosis of Benign Paroxysmal Positional Vertigo

  • Clinical evaluation

  • Gadolinium-enhanced MRI if findings suggest central nervous system (CNS) lesion

The diagnosis of BPPV is based on characteristic symptoms, nystagmus Nystagmus Nystagmus is a rhythmic movement of the eyes that can have various causes. Vestibular disorders can result in nystagmus because the vestibular system and the oculomotor nuclei are interconnected... read more elicited by the Dix-Hallpike maneuver Nystagmus (also called the Barany maneuver), and the absence of other abnormalities noted during neurologic examination. Such patients require no further testing.

In the Dix-Hallpike (a provocative test for positional nystagmus), the following occur:

  • The patient sits erect on an examination table so that when the patient lies back, the head extends beyond the end of the examination table.

  • With support, the patient is rapidly lowered to a horizontal position, and the head is extended back 45° below horizontal and rotated 45° to the left.

  • The patient is told to fixate the eyes on a single location; visual fixation can shorten or even abolish nystagmus, so the maneuver is ideally done with the person wearing Frenzel lenses to make visual fixation on anything impossible.

  • The patient is returned to an upright position, and the maneuver is repeated with rotation to the right.

  • Then the patient lies face down so that the head remains turned at 45° degrees and the head hangs over the examination table by about 20°.

  • Vertigo and nystagmus can take about 5 to 10 seconds (sometimes up to 30 seconds) to appear (latency). Symptoms last 10 to 30 seconds, then decrease and disappear (ie, fatigue).

Duration of nystagmus and development of vertigo are noted. Nystagmus is torsional and occurs when the head is turned to the affected ear. Any position or maneuver that causes nystagmus should be repeated to see whether the nystagmus fatigues.

Unlike the positional nystagmus caused by BPPV, positional nystagmus caused by a CNS lesion has the following characteristics:

  • Lacks latency, fatigability, and severe subjective sensation

  • May continue for as long as the position is maintained

  • May be vertical or change direction

  • If rotary, is likely to be in an unexpected direction

If patients have nystagmus suggesting a CNS lesion, gadolinium-enhanced MRI of the brain and internal auditory canal is performed.

Treatment of Benign Paroxysmal Positional Vertigo

  • Provocative maneuvers to fatigue symptoms

  • Canalith repositioning maneuvers

BPPV usually subsides spontaneously in several weeks or months but may continue for months or years.

Because brief episodes can recur over a long period of time, medications (such as those used in Meniere disease Treatment Meniere disease is an inner ear disorder that causes vertigo, nausea, fluctuating sensorineural hearing loss, and tinnitus. There is no reliable diagnostic test. Vertigo and nausea are treated... read more ) are not recommended. Often, the adverse effects of medications worsen dysequilibrium.

Because BPPV is fatigable, one therapeutic approach is to have the patient perform provocative maneuvers early in the day in a safe environment. Symptoms are then minimal for the rest of the day.

Canalith repositioning maneuvers (most commonly the Epley maneuver Epley maneuver: A simple treatment for a common cause of vertigo Epley maneuver: A simple treatment for a common cause of vertigo or, less commonly, the Semont, maneuver or Brandt-Daroff exercises) involve moving the head through a series of specific positions intended to return the errant canalith to the utricle. After the Epley or Semont maneuver is done, the patient should try to avoid neck flexion or extension for 1 to 2 days. These maneuvers can be repeated as necessary. The Brandt-Daroff exercises are done 5 times in a row, 3 times/day, for about 2 weeks or until there is no vertigo with the exercise. All of these maneuvers can be done by the patient at home.

Epley maneuver: A Simple Treatment for a Common Cause of Vertigo

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

Epley maneuver: A Simple Treatment for a Common Cause of Vertigo

For the Semont maneuver, the patient is seated upright in the middle of an examination table. The patient’s head is rotated toward the unaffected ear; this rotation is maintained throughout the maneuver. Next, the torso is lowered laterally onto the examination table so that the patient is lying on the side of the affected ear with the nose pointed up. After 3 minutes in this position, the patient is quickly moved through the upright position without straightening the head and is lowered laterally to the other side now with the nose pointed down. After 3 minutes in this position, the patient is slowly returned to the upright position, and the head is rotated back to normal.

The Brandt-Daroff exercise can be taught to the patient. The patient sits upright, then lies on one side with the nose pointed up at a 45-degree angle. The patient remains in this position for about 30 seconds or until the vertigo subsides and then moves back to the seated position. The same motion is repeated on the opposite side. This cycle is repeated 5 times in a row, 3 times/day, for about 2 weeks, or until there is no more vertigo with the exercise.

Key Points

  • In BPPV, vertigo is caused by displacement of otoconial crystals into a semicircular canal; symptoms are triggered by head movement.

  • Nausea and vomiting may also occur, but not tinnitus or hearing loss.

  • Diagnosis is clinical, but some patients require MRI to rule out other conditions.

  • Treat with canalith-repositioning maneuvers.

  • Medications rarely help and may worsen symptoms.

Drugs Mentioned In This Article

Drug Name Select Trade
AcidFree, Alka-Mints, Alka-Seltzer, Alka-Seltzer Heartburn Relief, Alkets , Antacid Fast Dissolve, Calcarb 600, Calci-Chew , Calci-Mix , Calcium Antacid, Cal-Gest , Caltrate, Maalox, Maalox Antacid Barrier, Maalox Quick Dissolve, Mylanta Children's, Nephro-Calci , Pepto-Bismol Children's, Rolaids Extra Strength, Titralac, Titralac Extra Strength, Tums, Tums Chewy Bites , Tums Cool Relief, Tums E-X, Tums Freshers, Tums Kids, Tums Lasting Effects, Tums Smooth Dissolve, Tums Smoothies, Tums Ultra
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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