Vertigo (benign paroxysmal positional vertigo)

Vertigo is the sensation that you or your surroundings are moving or spinning when there is no actual movement. Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo. It occurs when tiny calcium carbonate crystals (otoconia) become dislodged from their usual location in the utricle and enter one of the semicircular canals, disrupting normal fluid movement and sending false signals to the brain.

BPPV causes brief episodes of spinning triggered by changes in head position — rolling over in bed, looking up, or bending down. It is not life-threatening, but it can be intense and increase fall risk. Canalith repositioning maneuvers (such as the Epley maneuver) are highly effective at moving the crystals back and relieving symptoms.

BPPV symptoms include:

• Brief episodes of spinning vertigo (usually less than one minute) triggered by specific head movements
• A sense of unsteadiness that may linger between spells
• Nausea, and occasionally vomiting, with severe episodes
• Abnormal rhythmic eye movements (nystagmus) during attacks
• No hearing loss or tinnitus in typical BPPV (those symptoms suggest other inner-ear disorders)

Symptoms often come and go and may resolve for weeks or months and then return. Vertigo that is continuous, associated with severe headache, double vision, weakness, dysarthria, or difficulty walking requires urgent evaluation for central causes (stroke, etc.).

In BPPV, otoconia from the utricle migrate into a semicircular canal (most often the posterior canal). Head position changes then cause the crystals to move, stimulating hair cells inappropriately and creating a false sense of rotation. BPPV may follow head trauma, prolonged bed rest, inner-ear disease, or occur idiopathically — especially with aging as the crystals become more fragile. Other causes of vertigo include vestibular neuritis, Ménière’s disease, vestibular migraine, medications, and central neurologic disorders.

Risk factors for BPPV include:

• Age over 50
• Female sex
• Prior head injury
• Other inner-ear disorders (including prior vestibular neuritis)
• Prolonged recumbency
• Osteoporosis (association in some studies)
• Migraine history in some people

BPPV itself does not cause permanent inner-ear damage, but complications can include:

• Falls and injuries from sudden vertigo
• Reduced activity and deconditioning from fear of triggering spells
• Nausea-related dehydration in severe cases
• Recurrence (common; maneuvers can be repeated)

BPPV cannot always be prevented. After successful treatment, some clinicians advise sleeping with the head slightly elevated and avoiding prolonged positions with the treated ear dependent for a short period, though evidence for strict post-maneuver restrictions is mixed. Prompt treatment of head injuries and maintaining activity may help overall vestibular health.

BPPV is diagnosed clinically with positional testing:

• Dix-Hallpike test — for posterior canal BPPV; produces characteristic upbeat-torsional nystagmus after a brief latency
• Supine roll test — for horizontal canal BPPV

A positive test with typical nystagmus confirms the diagnosis and identifies the affected canal and side. Imaging and audiometry are reserved for atypical features, neurologic signs, or failure to respond to appropriate maneuvers. Bedside HINTS examination (by trained clinicians) helps distinguish peripheral from central vertigo in acute continuous cases.

See a clinician for new, severe, or recurrent vertigo. Seek emergency care if vertigo is accompanied by headache unlike any other, double vision, speech difficulty, weakness, numbness, trouble walking, or loss of consciousness — possible signs of stroke or other central nervous system problems.

First-line treatment for BPPV is canalith repositioning:

• Epley maneuver (or modified Epley) for posterior canal BPPV — series of head and body position changes that guide crystals back to the utricle
• Semont (Liberatory) maneuver — alternative for posterior canal
• Lempert (barbecue) roll or Gufoni maneuver for horizontal canal BPPV
• Maneuvers can be performed in the office and taught for home use when appropriate
• Vestibular suppressant medicines (meclizine, benzodiazepines) may reduce nausea briefly but can slow adaptation and are not a primary treatment for BPPV
• Rare refractory cases may be referred for specialist care; surgical canal plugging is seldom needed

Most people improve substantially after one or two properly performed maneuvers.

After diagnosis and treatment:

• Perform prescribed repositioning maneuvers as instructed
• Move carefully when getting out of bed or looking up while symptoms are active
• Use good lighting at night to reduce fall risk
• Sit down immediately if vertigo starts
• Avoid driving or operating machinery during active spells
• Follow up if symptoms persist so the maneuver can be repeated or the diagnosis reconsidered

Bring:

• Description of spells (spinning vs lightheadedness, duration, triggers such as rolling in bed or looking up)
• Associated symptoms (hearing change, tinnitus, headache, neurologic deficits)
• Recent head injury or ear infections
• List of medicines
• Questions about canalith repositioning and what to do if symptoms return