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Benign Paroxysmal Positional Vertigo

(Benign Positional Vertigo; Benign Postural Vertigo; BPPV)

By

Lawrence R. Lustig

, MD, Columbia University Medical Center and New York Presbyterian Hospital

Last full review/revision Jun 2021| Content last modified Jun 2021
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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. Drugs 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 (and rarely in the superior semicircular canal), creating the illusion of motion. Etiologic factors include

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 (a provocative test for positional nystagmus), and on absence of other abnormalities on neurologic examination. Such patients require no further testing.

Unlike the positional nystagmus caused by BPPV, the positional nystagmus caused by a CNS lesion

  • 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 the unexpected direction

Patients with nystagmus suggesting a CNS lesion undergo gadolinium-enhanced MRI.

Treatment of Benign Paroxysmal Positional Vertigo

  • Provocative maneuvers to fatigue symptoms

  • Canalith repositioning maneuvers

  • Drug treatment typically not recommended

BPPV usually subsides spontaneously in several weeks or months but may continue for months or years. Because the condition can be long-lasting, drug treatment (like that used in Meniere disease Treatment Meniere disease is an inner ear disorder that causes vertigo, fluctuating sensorineural hearing loss, and tinnitus. There is no reliable diagnostic test. Vertigo and nausea are treated symptomatically... read more ) is not recommended. Often, the adverse effects of drugs worsen dysequilibrium.

Because BPPV is fatigable, one therapy 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 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... read more , or, alternatively, 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 performing the Epley or Semont maneuvers, the patient should try to avoid neck flexion or extension for 1 to 2 days. These maneuvers can be repeated as necessary. In contrast, the Brandt-Daroff exercises are performed by the patient at home 5 times in a row, 3 times/day, for about 2 weeks or until there is no vertigo with the exercise.

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 a stretcher. 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 stretcher 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.

Brandt-Daroff exercises 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

  • Vertigo occurs due to displacement of otoconial crystals into a semicircular canal; symptoms are triggered by head movement.

  • There is usually nausea and vomiting but no tinnitus or hearing loss.

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

  • Treatment is with canalith-repositioning maneuvers.

  • Drugs rarely help and may worsen symptoms.

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