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Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is a problem in the inner ear. It is the most common cause of vertigo, which is a false sensation of spinning or movement.

BPPV: What You Need to Know

  • Benign paroxysmal positional vertigo (BPPV) is the most common of the inner ear disorders.

  • BPPV can affect people of all ages but is most common in people over the age of 60.

  • Most patients can be effectively treated with physical therapy. In rare cases, the symptoms can last for years.

What causes BPPV?

BPPV occurs when tiny calcium crystals called otoconia come loose from their normal location on the utricle, a sensory organ in the inner ear.

If the crystals become detached, they can flow freely in the fluid-filled spaces of the inner ear, including the semicircular canals (SCC) that sense the rotation of the head. Otoconia will occasionally drift into one of the SCCs, usually the posterior SCC given its orientation relative to gravity at the lowest part of the inner ear.

The otoconia will not cause a problem when located in an SCC until the person’s head changes position, such as when looking up or down, going from lying to seated or lying to seated in bed, or when rolling over in bed. The otoconia move to the lowest part of the canal, which causes the fluid to flow within the SCC, stimulating the balance (eighth cranial) nerve and causing vertigo and jumping eyes (nystagmus).

BPPV Symptoms

People with BPPV can experience a spinning sensation — vertigo — any time there is a change in the position of the head.

The symptoms can be very distressing. People can fall out of bed or lose their balance when they get up from bed and try to walk. If they tilt their head back or forward while walking, they may even fall, risking injury. Vertigo can cause the person to feel quite ill with nausea and vomiting.

While the hallmark of BPPV is vertigo associated with changes in head position, many people with BPPV also feel a mild degree of unsteadiness in between their recurrent attacks of positional vertigo.

The onset of BPPV may be abrupt and frightening. People may think they are seriously ill; for example, they may fear they are having a stroke. A doctor’s diagnosis of BPPV can be reassuring, especially when people understand that help is available to relieve their symptoms.

Without treatment, the usual course of the illness is lessening of symptoms over a period of days to weeks, and sometimes there is spontaneous resolution of the condition. In rare cases, the person’s symptoms can last for years.

What brings on BPPV?

In many people, especially older adults, there is no specific event that causes BPPV to occur, but there are some things that may bring on an attack:

  • Mild to severe head trauma

  • Keeping the head in the same position for a long time, such as in the dentist chair, at the beauty salon or during strict bed rest

  • Bike riding on rough trails

  • High intensity aerobics

  • Other inner ear disease (ischemic, inflammatory, infectious)

BPPV Diagnosis

Diagnosing BPPV involves taking a detailed history of a person’s health. The doctor confirms the diagnosis by observing nystagmus — jerking of the person’s eyes that accompanies the vertigo caused by changing head position. This is accomplished through a diagnostic test called the Dix-Hallpike maneuver.

First, while sitting up, the person’s head is turned about 45 degrees to one side. Next, the patient is quickly laid down backward with the head just over the edge of the examining table. This move can often bring on the vertigo and the doctor can observe to see if the person’s eyes show the jerking pattern of nystagmus. A positive response confirms the diagnosis of BPPV. An MRI or CT scan of the brain is usually unnecessary.

A doctor’s diagnosis of BPPV can be reassuring, especially when the patient understands that help is available to relieve the symptoms. Even without treatment, the usual course of the illness is lessening of symptoms over a period of days to weeks, and sometimes there is spontaneous resolution of the condition.

BPPV Treatment

The Epley Maneuver for BPPV

BPPV with the most common variant (crystals in the posterior SCC) can be treated successfully — with no tests, pills, surgery or special equipment — by using the Epley maneuver.

This simple, effective approach to addressing BPPV involves sequentially turning the head in a way that helps remove the crystals and help them float out of the semicircular canal. Several repositioning maneuvers performed in the same visit may be necessary.

The Epley maneuver and other bedside physical therapy maneuvers and exercise programs can help reposition the crystals from the semicircular canals. Recurrences can occur, and repeat repositioning treatments are often necessary.

After Epley maneuver treatment, the patient may begin walking with caution. He or she should avoid putting the head back, or bending far forward (for example, to tie shoes) for the remainder of the day. Sleeping on the side of the affected ear should be avoided for several days.

If the crystals are in a location other than the posterior semicircular canal, slightly different maneuvers may be used, but they are based on the same principle of moving the stones out of the offending semicircular canal. BPPV of the anterior canal is exceedingly rare, since debris in this canal (located at the top of the inner ear) easily falls out on its own.

Other Treatments for BPPV

Usually no medications are required for BPPV unless the patient has severe nausea or vomiting. If extreme nausea is present, the doctor may prescribe or administer anti-nausea medications, especially if the person would not be able to tolerate repositioning maneuvers otherwise.

Surgery is seldom necessary to treat this condition. In rare cases, the doctor may recommend a surgical procedure to block the posterior semicircular canal to prevent stones from entering and moving within the canal. While the surgical plugging procedure cures the problem, it carries some risk, including hearing loss.

Over the long term, BPPV recurs in about half of people who experience it. For those who experience frequent recurrence, home exercises can help them manage symptoms themselves.

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