Benign Paroxysmal Positional Vertigo (BPPV)
NICE CKS Benign paroxysmal positional vertigo. Last revised: Apr 2022.
Guidelines
Investigation and Diagnosis
Clinical diagnosis via Dix-Hallpike manoeuvre
- Imaging is not usually required unless there are suggestive features of central vertigo causes
A +ve Dix-Hallpike manoeuvre can diagnose posterior semi-circular canal BPPV if it triggers:
- Vertigo, and
- Torsional (rotatory) and upbeating nystagmus, and
- Rotatory component direction is towards the affected ear (the downward-facing ear)
See this link for a video of the Dix-Hallpike manoeuvre.
During the Dix-Hallpike manoeuvre, the examiner observes both eyes for nystagmus, which is usually present in both eyes. The key diagnostic feature is the direction of the nystagmus, not which eye its more visible in.
Be cautious when performing the Dix-Hallpike manoeuvre if the person has
- Neck or back problem, or
- Cardiovascular problems such as carotid sinus syncope
As it involves turning the head and extending the neck
Management
Conservative Management / General Advice
Counsel the patient that:
- Most people recover over several weeks (even without treatment) but symptoms can last much longer and may recur
- A simple repositioning manoeuvre (see below) can help alleviate their symptoms in most cases
Advise the patient to:
- To get out of bed slowly and avoid tasks which involve looking upwards
Patients who are suffering from vertigo must stop driving immediately.
The DVLA states that people with 'liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness' should stop driving and inform the DVLA. However, BPPV is generally not spontaneous or unprovoked, most people with BPPV can continue to drive.
Repositioning Manoeuvres
Discuss the option of watchful waiting without treatment or treatment with repositioning manoeuvre
Choice of repositioning manoeuvre:
- 1st line: Epley manoeuvre (done by clinician) (ideally performed at first presentation in primary care)
- 2nd line: Semont manoeuvre (done by clinician)
- 3rd line: Brandt-Daroff exercises (for the patient to perform at home)
Note that symptomatic drug treatment (like prochlorperazine, antihistamines) used in other peripheral vertigo disorders is NOT usually helpful in BPPV.
Be cautious with performing the Epley manoeuvre or Semont manoeuvre if the person has:
- Neck or back problems
- Unstable cardiac disease
- Suspected vertebrobasilar disease
- Carotid stenosis
- Morbid obesity
If any doubt about the safety of the procedure, seek specialist advice or refer to balance specialist.