Benign Paroxysmal Positional Vertigo (BPPV)
Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder, characterised by repeated episodes of positional vertigo, where vertigo occurs with changes in the head position.
This updated UKMLA guide to BPPV is based on NICE CKS, which covers causes, risk factors, symptoms, diagnosis and management.
Peripheral Vertigo: Key Differentials
| Feature | BPPV | Meniere’s disease | Vestibular neuronitis | Labyrinthitis |
|---|---|---|---|---|
| Core mechanism | Displaced otoconia in semi-circular canals | Inflammation of the vestibular portion of CN VIII | Inflammation of the labyrinth (affecting both vestibular and cochlear structures) | Endolymphatic hydrops |
| Course | Recurrent attacks, may resolve spontaneously | Recurrent attacks + progressively worsen over time | Singe acute episode | Singe acute episode |
| Trigger | Change in head position | Spontaneous | Spontaneous | Spontaneous |
| Vertigo duration | <1 min | 20 min to 24 hours | Days to weeks | Days to weeks |
| Cochlear symptoms (hearing loss, tinnitus) | Absent | Present | Absent | Present |
| Diagnosis | Dix-Hallpike test | Clinical diagnosis + audiometry | Clinical diagnosis | Clinical diagnosis |
| Management | Epley manoeuvre and other repositioning manoeuvres +/- vestibular rehabilitation | Short-term vestibular suppressants +/- betahistine | Short-term vestibular suppressants +/- vestibular rehabilitation | Short-term vestibular suppressants +/- vestibular rehabilitation |
Causes
Most common mechanism: presence of loose otoconia (calcium carbonate debris) in the semi-circular canals of the inner ear
- When the head moves, otoconia move within the semi-circular canals
- This causes motion of the endolymph, which induces the symptom of vertigo
BPPV is usually unilateral, only affecting one canal:
- 85-95%: posterior semi-circular canal
- 8-15%: horizontal or lateral canal
- 1-2%: anterior canal
Risk Factors
BPPV can be precipitated by:
- Head injury
- Prolonged recumbent position (lying horizontally) (e.g. dental procedures, hairdressing procedures)
- Ear surgery
- Inner ear pathologies (e.g. Meniere’s disease, vestibular neuronitis, labyrinthitis)
Other risk factors:
- Increasing age
- Female
- Migraine
- Recent viral URTI
- Low serum vitamin D levels
Clinical Features
BPPV most commonly presents between 50-70 y/o
| Course of disease | BPPV often has a relapsing and remitting course
|
| Triggers | Specific movements that rotate the head relative to gravity can trigger an episode
Examples include:
|
| Presentation | Classically episodic vertigo episodes
Other associated features:
In the elderly, BPPV may contribute to falls. |
Cochlear symptoms (i.e. hearing and tinnitus) are NOT a feature of BPPV. Their presence is more suggestive of Meniere’s disease or labyrinthitis.
Investigation and Diagnosis
BPPV is a clinical diagnosis via the Dix-Hallpike manoeuvre
- A non-invasive clinical manoeuvre – see this link for a video demonstration
- Posterior semi-circular canal BPPV (the most common type) can be diagnosed if the manoeuvre triggers:
- Vertigo, and
- Torsional / rotatory and upbeating nystagmus, and
- Rotatory component direction is towards the affected ear (the downward-facing ear)
Imaging is NOT routinely required to diagnose BPPV.
Be cautious when performing the Dix-Hallpike manoeuvre if the person has:
- Neck or back problem (e.g. cervical spondylosis, cervical myelopathy, spinal deformity, RA affecting the cervical spine, vertebrobasilar insufficiency), or
- Cardiovascular problems such as carotid sinus syncope
As it involves turning the head and extending the neck
Imaging is NOT routinely required to diagnose BPPV.
If central causes of acute vertigo (e.g. cerebrovascular event) are suspected, immediate hospital admission is necessary.
Red flag features of central vertigo:
- New focal neurological deficit (e.g. facial weakness, limb weakness or sensory loss, diplopia, dysphagia)
- New unilateral hearing loss
- Cerebellar features (e.g. dysdiadochokinesis, ataxia, intentional tremor, slurred speech, hypotonia)
- New-onset headache
- HINTS examination suggesting a central cause:
- Normal head impulse test
- Vertical or direction-changing nystagmus
- Vertical skew deviation
Management
Conservative / General Management
| Patient education |
|
| Safety issues | The person should NOT drive when they are suffering from vertigo, or if they experience episodes of vertigo while driving
Inform their employer if their vertigo poses a risk in the workspace (e.g. ladder usage, heavy machinery operation, driving) Discuss the risk of falls and preventive measures |
Active Treatment
Discuss the option of:
- Watchful waiting (to see whether symptoms settle without treatment), or
- Repositioning manoeuvre (resolves symptoms more quickly)
Choice of repositioning manoeuvre:
- 1st line: Epley manoeuvre (done by clinician)
- Symptoms may improve shortly after treatment, but full recovery can take days to weeks
- If symptoms do not settle after 1 week, advise the person to return and consider repeating the manoeuvre
- 2nd line: Semont manoeuvre (done by clinician – less commonly performed)
- 3rd line: Brandt-Daroff exercises (for the patient to perform at home)
Symptomatic drug treatment (antiemetics like prochlorperazine, antihistamines) used in other peripheral vertigo disorders are NOT usually helpful in BPPV.
Be cautious when 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 a balance specialist.