Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is a common disorder of the inner ear thought to be caused primarily by otoconia (canaliths) dislodging and migrating into one of the semicircular canals, most commonly the posterior semicircular canal, where it disrupts the endolymph dynamics. BPPV is the most common cause of peripheral vertigo. The primary symptom of BPPV is episodic vertigo that lasts < 1 minute, triggered by sudden changes in head posture in relation to gravity (e.g., bending forwards, rapidly standing up). BPPV is a clinical diagnosis that is supported by a combination of characteristic features as well as the presence of nystagmus and vertigo elicited by provoking maneuvers (e.g., Dix-Hallpike test). Canalith repositioning maneuvers (CRM), such as the Epley maneuver, are the preferred treatment of BPPV. Vestibular rehabilitation may be used as an adjunct to (CRM). Vestibular suppressants and surgery are reserved for patients with intractable or severely-disabling BPPV.

See also “Vertigo.”

Episodic vertigo triggered by certain changes in the position of the head ^[1]

BPPV can be classified into the following subtypes depending on which semicircular canal is involved.

• Prevalence
  • BPPV is the most common type of peripheral vestibular vertigo with a prevalence of ∼ 2%. ^[5]
  • BPPV is the underlying cause in approx. 40% of geriatric patients presenting with dizziness. ^[1]
• Sex: ♀ > ♂ ^[1][5]
• Age: peak incidence between 50–60 years ^[5]

Epidemiological data refers to the US, unless otherwise specified.

Although the exact etiology is unknown in most patients with BPPV, the condition is thought to result from the dislodgement or abnormal adherence of otoconia (see “Pathophysiology” section). The etiology of dislodged or adherent otoconia is described here.

• Idiopathic
  • Most common ^[1]
  • Possibly secondary to degeneration of the acoustic macula ^[2]
• Secondary causes ^[2]
  • Trauma
    • Head injury ^[1]
    • Prior otologic surgery
  • Other inner-ear disorders
    • Vestibular neuritis
    • Meniere disease
  • Miscellaneous: migraine
• Risk factors ^[1][5]
  • Female sex
  • Increased age
  • Low vitamin D levels
  • Osteopenia or osteoporosis

Although incompletely understood, BPPV is thought to occur due to dislodged or abnormally adherent otoconia, causing semicircular canal dysfunction. ^[1][2]

• Otoconia (otoliths): physiological calcium carbonate crystals present within the utricle and saccule that serve to maintain balance and spatial orientation
• Canalithiasis
  • Dislodged, free-floating otoconia (endolymphatic debris).
  • Canalithiasis from the acoustic macula enter the semicircular canals → disruption of endolymph dynamics in response to changes in gravitational forces (e.g., changing head positions) → abnormal stimulation of the vestibular apparatus
• Cupulolithiasis: otoconial debris that has adhered to the cupula of the affected semicircular canal
  • Cupulolithiasis → increased sensitivity of the semicircular canal to changes in gravitational forces → abnormal stimulation of the vestibular apparatus
• Canalithiasis or cupulolithiasis → abnormal stimulation of the vestibulocochlear nerve in response to changes in head position and movement → severe vertigo attacks that last several seconds ^[1]

• Episodic vertigo (spinning sensation) ^[1][2]
  • Sudden (“paroxysmal”) and recurrent episodes
  • Lasts several seconds (typically ≤ 1 minute)
  • Triggered by certain head movements (positional vertigo) after a latency of a few seconds.
  • Associated with:
    • Nystagmus
    • Risk of falls and subsequent injury
    • Nausea and vomiting
• Triggers: Quick rotation of the head relative to gravity is the main trigger of BPPV (see ''Pathophysiology'' section). ^[1][2]
  • Lying down, reclining, or standing up quickly ^[5]
  • Rolling over in bed
  • Bending forwards
  • Suddenly jerking the head to look up or down
• Provoking maneuvers for BPPV: See “Diagnostics” section.

BPPV does not typically cause cochlear (e.g., hearing loss or tinnitus) or neurological symptoms.

Approach ^[1][5]

The following focuses on patients with triggered episodic vestibular syndrome; see “Approach to vertigo” for details on clinical evaluation, targeted testing (e.g., HINTS examination), and neuroimaging for patients with undifferentiated acute vestibular syndrome.

• BPPV is a clinical diagnosis based on characteristic findings and elicitation of nystagmus and vertigo on provoking maneuvers for BPPV.
• Patients with atypical features or suspected differential diagnoses: Consider further evaluation with audiometry, vestibular function testing, and/or neuroimaging as needed.
  • Consider other diagnoses if any of the following are present: ^[1]
    • Vertigo that lasts longer than one minute
    • Associated hearing loss
    • Associated neurological symptoms (e.g., gait disturbances) are present.
    • Failure to respond to canalith repositioning maneuvers or vestibular rehabilitation therapy ^[6]

Diagnostic criteria for posterior semicircular canal BPPV ^[1]

All of the following criteria should be met to confirm the clinical diagnosis of posterior canal BPPV. ^[5]

• Episodic vertigo triggered by changes in head position in relation to gravity
• Elicitation of vertigo and nystagmus on performing Dix-Hallpike maneuver, with the following characteristics:
  • Latency period: Vertigo and nystagmus manifest a few seconds after completing the maneuver.
  • Direction of nystagmus: upbeat torsional nystagmus
  • Duration: Vertigo and nystagmus increase and then resolve within 60 seconds after onset.

Provoking maneuvers for BPPV ^[1][5]

• Definition: set of specific sequential maneuvers used to provoke symptoms in an individual with suspected BPPV
• Findings: Positional vertigo associated with nystagmus triggered on specific maneuvers is considered a positive test and is diagnostic of BPPV.
  • The following characteristics of nystagmus should be noted:
    • Latency: typically 2–5 seconds
    • Direction: The direction of nystagmus indicates which specific canal is affected (see individual maneuvers below for more details).
    • Duration: < 1 minute (typically 30 seconds) ^[5]
    • Reversal: The pattern of nystagmus reverses direction when the patient is made to sit in a neutral position at the end of the provoking maneuver.
    • Fatigability: Intensity of nystagmus decreases on repeated sequential testing (not recommended). ^[1]
• Approach
  • The Dix-Hallpike maneuver should be performed in all patients with suspected BPPV to identify posterior canal BPPV.
  • If the Dix-Hallpike maneuver is negative, the supine head roll test should be performed to assess for lateral canal BPPV.

Dix-Hallpike maneuver ^[1][7]

• Indication
  • First-line test for suspected BPPV
  • Gold standard test to diagnose suspected posterior semicircular canal BPPV ^[1]
  • Suspected anterior semicircular canal BPPV
• Procedure
  1. Ask the patient to sit upright on the examination bed and to keep their eyes open during the procedure.
  2. Rotate the head by 45° towards the affected side.
  3. Keeping the neck rotated, quickly lay the patient in a supine position with the neck slightly extended (approx 20°) and the affected ear held down at 45°.
  4. Hold this position for 20–30 seconds.
     • Examine the eyes for nystagmus; if present note latency, direction, and duration of nystagmus
     • Inquire if the patient is experiencing vertigo
     • Wait for resolution of nystagmus and vertigo
  5. Slowly reposition the patient into an upright posture with neck in neutral position and observe for reversal of nystagmus.
  6. If negative (that is, no nystagmus/vertigo), repeat the maneuver with the head turned to the unaffected side in step 2.
• Characteristic findings
  • Positive Dix-Hallpike test: positional vertigo and nystagmus triggered during the maneuver
  • Direction of nystagmus
    • Posterior canal BPPV: upbeat nystagmus with ipsiversive torsional nystagmus component
    • Anterior canal BPPV: downbeat nystagmus with ipsiversive torsional nystagmus
• Further steps
  • Positive test: Perform Epley repositioning maneuver. ^[1][5]
  • Negative test ^[5][7]
    • BPPV not necessarily ruled out
    • Consider performing the Epley maneuver anyway.
    • Consider ENT consultation for special maneuvers.
    • Evaluate for other causes of vertigo and nystagmus.

Supine head roll test ^[1][5]

• Indication
  • Suspected BPPV with negative or atypical findings on Dix-Hallpike test
  • Lateral semicircular canal BPPV
• Procedure
  1. Ask the patient to lie in a supine position and to keep their eyes open during the procedure.
  2. Position the patient's head in neutral position.
  3. Quickly turn the patient's head by 90° to one side and examine for nystagmus.
  4. Wait for nystagmus to subside.
  5. Reposition the patient's head to neutral position, reassess for nystagmus; allow nystagmus to subside.
  6. Repeat steps on the opposite side.
• Characteristic findings ^[1]
  • Positional vertigo and nystagmus triggered during the maneuver
  • Direction of nystagmus in lateral canal BPPV:
    • Bilateral horizontal nystagmus with eyes beating toward the ground (geotropic nystagmus)
    • Bilateral horizontal nystagmus with eyes beating toward the ceiling (apogeotropic nystagmus)

Additional diagnostic evaluation ^[1]

Audiometry ^[1]

• Indication: suspected hearing loss
• Supportive findings: typically normal in BPPV

Vestibular function tests ^[1]

• Definition: tests to identify nystagmus in response to vestibular stimulation and thereby assess the integrity and function of the vestibular apparatus of the inner ear
• Indications
  • BPPV with atypical nystagmus
  • Suspected concomitant vestibular pathology ^[1]
  • Refractory BPPV
• Supportive findings: Vestibular function is typically normal in BPPV.

Neuroimaging ^[8]

• Modalities
  • MRI head and internal auditory canal with and without IV contrast
  • CT temporal bone without IV contrast
• Indications ^[1][8]
  • Suspected BPPV with atypical features, such as:
    • No nystagmus or atypical direction of nystagmus on provoking maneuvers
    • Persistent vertigo
  • To rule out intracranial causes of vertigo
  • Preoperative planning for refractory BPPV
• Supportive findings: normal in BPPV ^[1]

• See “Causes of vertigo” for other etiologies of vertigo.
  • Causes of peripheral vertigo: e.g., meniere disease, vestibular neuritis
  • Causes of central vertigo: e.g., TIA, cerebellar stroke, vestibular migraine
• See “Differential diagnoses of vertigo” for other conditions that mimic vertigo: e.g., anxiety or panic disorder, postural hypotension, medication side effects

The differential diagnoses listed here are not exhaustive.

Although BPPV is often considered a condition that resolves spontaneously, canalith repositioning maneuvers (CRM) are the preferred first-line treatment. Vestibular rehabilitation therapy may be useful as an adjunct to CRM; both forms of therapy can be performed at home, by patients themselves. Patients with refractory symptoms or atypical symptoms should be evaluated for alternative diagnoses. ^[1][5]

Canalith repositioning maneuvers (CRM) ^[1]

• Definition: set of specific sequential maneuvers performed to mobilize the otoconia out of the involved semicircular canal and back into the vestibule
• Indication: first-line treatment for BPPV
• General considerations
  • CRM can be performed immediately after identifying the affected canal on a provoking maneuver.
  • A trained general practitioner can perform the Dix-Hallpike maneuver and Epley maneuver; ENT referral is recommended in patients with persistent or recurrent symptoms. ^[9][10]
  • Potential side effects include nausea, vomiting, and postural instability lasting for approximately 24 hours.
  • Antiemetics or vestibular suppressants may be administered prophylactically before performing CRM.
  • Patients with frequent recurrences can be taught to perform these maneuvers themselves at home.
• Outcome
  • Up to 80–90% success rate ^[6][11]
  • Recurrences requiring repeat CRM are expected. ^[5][12]
  • Canal conversion

Epley maneuver ^[1][5]

• Indication
  • Posterior semicircular canal BPPV after a positive Dix-Hallpike maneuver
  • Anterior semicircular canal BPPV after a positive Dix-Hallpike maneuver ^[4]
• Procedure
  1. The initial steps are the same as those of the Dix-Hallpike maneuver
     • Ask the patient to sit upright on the examination table and to keep their eyes open during the procedure.
     • Rotate the head by 45° towards the affected side.
     • Keeping the neck rotated, quickly lay the patient in a supine position with the neck slightly extended (approx 20°) and the affected ear facing down at 45°
  2. Hold this position for 30 seconds or until the resolution of nystagmus.
  3. Turn the patient's head by 90° toward the unaffected side; hold this position for 30 seconds or until resolution of nystagmus.
  4. Turn the patient's head and body by 90° towards the unaffected side such that the patient is now lying on their side with their face turned toward the ground.
  5. Hold this position for 30 seconds or until the resolution of nystagmus.
  6. Bring the patient back to a seated, upright position with the head in the neutral position.
  7. After completion of the maneuver, ask the patient to remain in this position for about 15 minutes.

Vestibular rehabilitation therapy ^[1]

Vestibular rehabilitation refers to different physical exercises to treat dizziness and balance disorders that the patients perform either at home or with the help of a clinician.

• Indications
  • Adjunctive therapy to CRM ^[1]
  • Refractory BPPV
  • Patient refusal or contraindications to CRM
  • Patients with preexisting conditions may benefit the most.
• Goal: induce vestibular habituation or adaptation to gravitational changes to minimize the frequency of episodic vertigo
• Options
  • There are several exercises for vestibular rehabilitation (e.g., Brandt-Daroff exercise, Cawthorne-Cooksey exercise) that are especially helpful for BPPV.
  • Exercises may be customized by a trained specialist

Observation (watchful waiting) ^[1]

• Indication ^[6]
  • Mild, infrequent symptoms
  • Relative contraindications to CRM
  • History of complications from prior CRM
  • Patient refusal of CRM
• Relative contraindication: patients at high risk of falls or severe injury from falls ^[6]
• Procedure
  • Withhold CRM and vestibular rehabilitation
  • Advise patients to avoid postures or activities that trigger symptoms (see ''Triggers'' in ''Clinical Features” section).
  • Reassess patients after 1 month
    • Symptom frequency decreased: Continue observation.
    • Symptoms disabling: Consider CRM and/or vestibular rehabilitation.

Medical therapy (vestibular suppressants) ^[1]

Vestibular suppressants are not routinely indicated due to their adverse effect profile and potential of suppressing the central vestibular compensatory system. Patients should be counseled about their potential side effects.

• Indications
  • Symptomatic control during an acute attack (rare)
  • Intractable BPPV
  • Patients who refuse to undergo canalith repositioning maneuvers
  • Before provoking or repositioning maneuvers
• Options: See “Vestibular suppressants”.
• Duration of therapy
  • As short a period as possible
  • Acute attacks or premaneuver prophylaxis: One-time dosing may be adequate.
  • In patients with severe intractable BPPV: variable; 2–6 months ^[13]

Chronic use of vestibular suppressants is contraindicated in BPPV because it can inhibit central compensation and potentially exacerbate chronic gait and postural instability. ^[1]

Surgical treatment ^[2]

• Indication
  • Intractable BPPV
  • Severe and frequent recurrences
• Options
  • Singular neurectomy
  • Posterior semicircular canal occlusion

• Postural instability and falls, which can lead to: ^[1]
  • Fractures (e.g., Colles fracture, hip fracture)
  • Dislocations (e.g., hip dislocation)
  • Traumatic brain injury (e.g., hemorrhagic stroke, concussion)
• Depression
• Decreased quality of life

We list the most important complications. The selection is not exhaustive.

• Spontaneous resolution (with observation alone) ^[2][6]
  • Approx. 25% at 1 month
  • Approx. 50% at 3 months
• Recurrence rate: annually around 15% ^[5]