creation date: 2025-07-01 18:17 tags: Pathologies
Benign Paroxysmal Positional Vertigo
Background
Definitions
Benign paroxysmal positional vertigo (BPPV) is a common form of vertigo. It accounts for about half of the cases of peripheral vestibular dysfunction.
BPPV is a type of vertigo, the workup of which is discussed separately.
Etiology and Pathogenesis
BPPV is due to canalithiasis which refers to calcium debris within the semicircular canal. The debris are likely loose otoconia (calcium carbonate crystals) from the utricular sac.
Debris within the canal causes inappropriate movement of the endolymph during acceleration. This gives the sensation of spinning when the head shifts relative to gravity. The clinical manifestation may vary based on the site of canalithiasis, with the most common being the posterior semicircular canal followed by the anterior and horizontal canals.
A number of causes are theorized to cause BPPV:
- Giant cell arteritis may be related to ischemic complications
- Bone loss may be the source of the calcium carbonate
Specific to posterior canal BPPV:
- Idiopathic (35%+)
- Prior head trauma including whiplash injury (15-30%)
- Residual from other vestibular pathologies (eg. Meniere disease)
Clinical Presentation
Signs & Symptoms
Primary symptom is recurrent episodes of vertigo that lasts one minute of less.
- Provoked by specific types of head movement (eg. when looking up)
- May be associated with nausea and vomiting
- Recur periodically for weeks to months without treatment
Hearing loss is not associated with BPPV.
Provoking maneuvers can elicit nystagmus. Note that false positive can occur so such maneuvers should be used when clinical suspicion is present.
- Posterior canal BPPV: vertigo and nystagmus is provoked when affected ear is turned downwards during the Dix-Hallpike maneuver.
- Horizontal canal BPPV: turning the head while lying down or head turns while upright, but not by getting in and out of bed or extending the neck.
- Anterior canal BPPV: similar to posterior but with upward turning nystagmus.
History & Physical Exam
History should assess that symptoms are consistent with BPPV. It is important to rule out more concerning diagnoses.
It is important to verify the patient is in fact experiencing vertigo and not pre-syncope as postural hypotension can be confused with BPPV due to positional element.
Physical exam should check for alternative causes of vertigo including foreign bodies within the ear canal.
Provoking maneuvers should also be done to confirm a diagnosis which includes the Dix-Hallpike maneuver and turning the head for horizontal canal BPPV. The Dix-Hallpike maneuver is done as visualized:
Risk factors
The majority of BPPV cases are idiopathic and thus may not have risk factors that precipitate it.
In other causes, head trauma, ischemia, and iatrogenic sources (such as inner ear surgery) may increase the risk of canalithiasis and thus BPPV.
Migraines may also be associated with BPPV.
Diagnosis
Criteria
Diagnosis of BPPV is made if patient has recurrent, brief (<1 minute) episodes of vertigo provoked by specific head movement and confirmed by provoking maneuver.
Diagnostic criteria are proposed as follows: Posterior canal BPPV
- Nystagmus and vertigo appear with a few second latency and lasts less than 30 seconds
- Nystagmus beats upwards and torsionally, with upper poles of the eyes beating towards the ground
- After nystagmus stops and patient sits up, nystagmus recurs and beats in opposite direction
- Intensity and duration of nystagmus dimishes with repetition Anterior canal BPPV
- Like posterior canal except:
- Nystagmus is downbeat and torsional, with upper poles beating away from the ear (upwards) Horizontal canal BPPV
- Head turns laterally while supine results in nystagmus
- Appearance of nystagmus may suggest position of debris within the canal
Note that criteria may not be seen on examination which has been called “subjective BPPV”.
Work-up
The BPPV workup consist of ruling out alternative causes of vertigo. This is discussed separately.
Additional diagnostic testing is typically not indicated as findings are typically normal.
Differential
- Postural hypotension - rule out by history of vertigo and not presyncope
- Chronic unilateral vestibular hypofunction - associated with rapid head turns causing 1-2 second dizziness; vertigo does not require rapidity and lasts longer typically
- Vestibular paroxysmia - brief attacks of vertigo recurring several times a day which can occur unprovoked
- Vestibular migraine - isolated positional vertigo that can last up to several hours (but can last shorter like BPPV too). Typically accompanied by migraine headache.
- Central positional vertigo - downbeat nystagmus which can be confused with anterior canal BPPV but lacks latency and fatiguability
- Rotational vertebral artery syndrome - compression of vertebral artery by C1-C2 causing vertigo and nonspecific dizziness in additional to other brainstem symptoms
Red Flags / Complications
BPPV is benign as the name suggests and typically resolves itself after a period of time.
Residual nonpositional vague dizziness can persist which can cause complications relating to falls and quality of life.
Management
Non-pharmacological
In most cases, particle repositioning maneuvers are effective for treatment.
For posterior canal BPPV, a number of maneuvers exist but the modified Epley maneuver can be done in the office setting and at home as self treatment.
The procedure for left side BPPV is as follows:
This should be repeated three times a day until BPPV is not present for a 24 hour period.
For horizontal canal BPPV, the “barbecue rotation” maneuver/Lempert roll maneuver is used. The head is rotated in a supine position from the affected to the unaffected ear as follows:
For anterior canal BPPV, there is little evidence for maneuvers which are effective. Typically, the maneuvers used for posterior canal BPPV are used.
Pharmacological / Interventional
Medications are not useful for BPPV. However, in cases where patients could not tolerate the above maneuvers due to discomfort and nausea, betahistine 24mg BID for one week can be used along with maneuvers.
In cases of intractable BPPV, surgical treatments may be considered which ranges from surgical occlusion of the posterior canal to argon laser-induced ossification.