Benign Paroxysmal Positional Vertigo (BPPV)

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What is benign paroxysmal positional vertigo (BPPV)?

Benign paroxysmal positional vertigo is an inner ear problem that causes a spinning or whirling sensation when you move your head. That sensation is called vertigo. This vertigo usually lasts for less than a minute. It may be mild, or it may be bad enough to cause nausea.

What causes BPPV?

Experts do not know for sure, but suspect that particles of calcium normally found in your ear break off and float into the ear's semicircular canal. Once there, they interfere with your balance and cause vertigo. Medicines, disease, aging, or a head injury are some of the things that may cause the particles to break off.¹

Anyone can develop BPPV.

What are the symptoms of BPPV?

The main symptom is vertigo—a feeling of spinning, whirling, or tilting—that occurs when you move your head certain ways. Turning over in bed, turning your head quickly, bending over, or tipping your head back may cause it. Sometimes the vertigo then causes nausea and vomiting.

When you repeat that head movement 3 or 4 times, the vertigo may get better each time and then stop happening. This is called fatigability. Only after several hours will the same movement again give you vertigo.

How is BPPV diagnosed?

BPPV is diagnosed with a physical examination and medical history. Your health professional may also have you perform the Dix-Hallpike test. For this, he or she will move your body and head in certain directions while watching the involuntary movements of your eyes. The pattern of your eye movements helps determine the cause of your vertigo.

How is BPPV treated?

Treatment usually involves a series of head movements to make the particles float to another part of your ear where they won't affect your balance. Vertigo may go away on its own if the particles move again or if the brain adjusts to the conflicting signals that control movement and balance.

If these movements don't relieve your vertigo, other head exercises may help. Medicines may be used to control nausea. Surgery may be tried when other treatments have failed.

Frequently Asked Questions

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Experts believe benign paroxysmal positional vertigo (BPPV) is probably the result of a buildup of particles in the inner ear. This is probably what happens:

• Tiny calcium particles, called canaliths, break off from their normal position in the inner ear and enter the semicircular canal.
• The particles build up in the canal.
• When you move your head a certain way, such as tipping it back to look up, the particles float around in the canal, brushing against tiny hairs that detect movement. The hairs mistakenly tell your brain that you are moving.
• Because your other balance systems do not detect the same movement, they send conflicting signals to your brain, and vertigo is the result.

The main symptom of benign paroxysmal positional vertigo (BPPV) is the feeling that you or your surroundings are spinning, whirling, or tilting. This sensation is called vertigo.

It is important to understand the difference between vertigo and dizziness. People often use the terms interchangeably, but they are different symptoms and may indicate different problems. Vertigo happens when your body's balance sensory systems disagree about what kind of movement they sense. You may find it hard to walk or stand. You may even lose your balance and fall. If your vertigo is bad enough, you may also have nausea and vomiting.

To determine whether your vertigo is caused by BPPV, your health professional will want to find out what causes it, how bad it is and how long it lasts. With BPPV:

• Tilting the head, looking up or down, rolling over in bed, or getting in and out of bed causes vertigo.
• It begins a few seconds after you move your head.
• It usually lasts less than a minute. The spinning sensation may be mild, or it may be bad enough to cause nausea and vomiting.
• Vertigo becomes less noticeable each time you repeat the same movement. After 3 to 4 repeats, the movement may no longer cause vertigo. Several hours may pass before the same movement again causes in vertigo.

Benign paroxysmal positional vertigo (BPPV) causes a whirling, spinning sensation even though you are not moving. If the vertigo is bad, it may also cause nausea or vomiting. The vertigo attacks happen when you move your head in a certain way, such as tilting it back or up or down, or by rolling over in bed. It usually lasts less than a minute. Moving your head to the same position again may trigger another episode of vertigo.

BPPV often goes away without treatment. Until it does, or is successfully treated, it can repeatedly cause vertigo with a particular head movement. Sometimes it will stop for a period of months or years and then suddenly come back.

Scientists think you're more likely to develop benign paroxysmal positional vertigo (BPPV) if you have one of these conditions:

• You are an older adult.
• You have a head injury.
• You have an inflammation of the nerve that connects the inner ear to the brain, a condition called vestibular neuronitis.
• You have ear surgery.

If you've had one episode of vertigo caused by BPPV, you are likely to have more.

Call your health professional immediately if you have the spinning, whirling sensation of vertigo together with any of the following:

• A head injury
• Complete, sudden hearing loss
• Weakness in an arm or leg
• Blurred or double vision
• Difficulty speaking
• Persistent numbness or tingling anywhere on your body.

Call your health professional to schedule an appointment if:

• This is the first time you have had an attack of vertigo.
• You have a low-pitched roaring, ringing, or hissing sound in your ear, especially if you have not had this before. This is called tinnitus.
• You have frequent or severe episodes of vertigo that interfere with your activities.
• You have an attack of vertigo that is different from what you were told to expect.
• You need medicine to control nausea and vomiting.

Watchful Waiting

If your symptoms suggest benign paroxysmal positional vertigo (BPPV), watchful waiting may be appropriate. BPPV may go away on its own in time. If it interferes with your normal daily activities or causes nausea and vomiting, treatment may be needed.

Who To See

The following health professionals are able to diagnose and treat BPPV and the causes of vertigo:

• Family doctor
• General practitioner
• Physician assistant
• Nurse practitioner
• Internist
• Otolaryngologist
• Neurologist

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Benign paroxysmal positional vertigo (BPPV) is diagnosed with a physical exam and from your medical history. However, diagnosing the cause of the spinning, whirling sensation of vertigo can be difficult. Several diseases, the side effects of medicines, and head injuries can also cause vertigo.

A Dix-Hallpike test may be done to help your health professional determine the cause of your vertigo. During this test, he or she will carefully observe any involuntary eye movements. This will help determine whether the cause of your vertigo is inside your brain, inner ear, or the nerve connected to your inner ear. The Dix-Hallpike test also can help determine which ear is affected.

Other tests may be done to help diagnose your condition:

• Electronystagmography, which attaches small wires to your face that measure eye movements. It looks for the special eye movements that happen when the inner ear is stimulated. The pattern of eye movements can point to the location of the cause of the vertigo, such as the inner ear or the central nervous system.
• Imaging tests, such as magnetic resonance imaging of the head (MRI) or computed tomography of the head (CT scan). These tests may be done if symptoms could be caused by a brain problem.
• Hearing testing to detect hearing loss. A special hearing test can determine whether the nerve from the inner ear to the brain is working correctly. Hearing loss with vertigo usually indicates a problem other than BPPV, such as Ménière's disease or labyrinthitis.

Benign paroxysmal positional vertigo (BPPV) may go away in a few weeks by itself. If treatment is needed, it usually consists of head exercises called liberatory maneuvers. These exercises will move the particles out of the semicircular canals of your inner ear to a place where they will not affect your balance.

Over time, your brain may react less and less to the confusing signals triggered by the particles in the inner ear. This is called compensation. Compensation occurs most quickly if you continue normal head movements, even though doing so causes the whirling sensation of vertigo. A Brandt-Daroff exercise may also be done to speed the compensation process. This exercise takes you from sitting to lying on the side that causes the worst vertigo. You'll remain in this position until either the vertigo goes away or until 30 seconds have passed. This movement is then repeated on the other side. These exercises are done twice a day for several weeks to months, or until the vertigo goes away.

Medicines called vestibular suppressants (such as antihistamines, sedatives, or scopolamine) reduce vertigo and may be tried if your symptoms are severe. However, using medications to control vertigo often extends the time needed for compensation to occur.

Antiemetic medications may also be used to reduce nausea and vomiting that can occur with vertigo.

In rare cases, surgery may be used to treat BPPV.

In most cases, benign paroxysmal positional vertigo (BPPV) cannot be prevented. It may simply be a consequence of getting older. However, some cases may result from head injuries. Wearing a helmet when bicycling, motorcycling, playing baseball, or doing other sports activities can protect you from a head injury and BPPV.

You can reduce the whirling or spinning sensation of vertigo when you have benign paroxysmal positional vertigo (BPPV) by taking these steps:

• Use two or more pillows at night.
• Avoid sleeping on your side with the ear causing the problem facing down.
• Get up slowly in the morning and sit on the edge of the bed for a moment before standing.
• Avoid leaning over to pick things up or tipping your head far back to look up.
• Be careful about reclining, such as when you are in the dentist's chair or having your hair washed at a hair salon.
• Be careful about participating in sports that require you to turn your head, lean over, or lie flat on your back.

You can also help yourself by doing balance exercises and taking safety precautions.

Taking safety precautions for vertigo, such as adding grab bars near the bathtub and toilet and keeping walking paths clear, may prevent accidents and injuries.

Balance exercises for vertigo, such as standing with your feet together, arms down, and slowly moving your head from side to side, may help you maintain your balance and improve symptoms of vertigo.

If your health professional treated you with a liberatory (Semont or Epley) maneuver, you may be instructed to restrict your head movement for about a day. Do this by sleeping with your head propped up, not sleeping on the affected side, and not tipping your head too far up or down.

If your health professional has you try the Brandt-Daroff exercise to help your brain adjust, you will need to do the exercises at home several times a day, possibly for weeks. The exercises will allow your brain to get used to the abnormal balance signals triggered by the particles in the inner ear.

Staying as active as possible usually helps the brain adjust more quickly. But that can be hard to do when moving is what causes your vertigo. Bed rest may help, but it usually increases the time it takes for the brain to adjust.

Medications do not cure benign paroxysmal positional vertigo (BPPV). However, they may be used to control severe symptoms, such as the whirling, spinning sensation of vertigo and the nausea and vomiting that may result.

Medication Choices

Medications to reduce the whirling sensation of vertigo are called vestibular suppressants. They include:

Antihistamines (such as Dramamine, Antivert, Benadryl).

Scopolamine (such as Transderm-Scop).

Sedatives (such as Valium, Klonopin).

Antiemetic medications may be used if you have nausea or vomiting along with the vertigo.

What To Think About

Medications that calm the inner ear (vestibular suppressants) may also slow down the brain's ability to adjust to the abnormal balance signals triggered by the particles in the inner ear. They should be taken only for 1 to 2 weeks to control severe symptoms.

Ear surgery is an option for treating benign paroxysmal positional vertigo (BPPV) only in severe cases when other treatments have not worked.

Exercises are used to treat benign paroxysmal positional vertigo (BPPV) These exercises move particles floating in the semicircular canals of your inner ear so that they don't affect your balance. Although the exercises usually stop the vertigo for months or years, the particles may return and cause your symptoms to come back.

Other Treatment Choices

Exercises that may be used to treat BPPV include:

• Liberatory maneuvers, such as the Semont or modified Epley maneuver. These exercises often cure BPPV by moving the particles in your inner ear so that they do not affect your balance. During these exercises, your health professional will help you hold your head in a series of positions. Often, one treatment is enough. You may be taught to do these exercises on your own at home.
• Brandt-Daroff exercise may be tried if liberatory maneuvers do not work. During this exercise, you will repeatedly go from a sitting position to a lying position until the vertigo stops. This exercise may help speed your brain's ability to adjust to the conflicting balance signals it is getting. You need to do these exercises several times a day for weeks for them to work.

What To Think About

These exercises can eliminate symptoms of BPPV and have about the same success rates. Liberatory maneuvers usually are more comfortable, and they work faster—in 1 or 2 treatments rather than being repeated several times a day for weeks. Therefore, liberatory maneuvers have become the first line of treatment.²

Organizations

• Labyrinthitis
• Ménière's Disease
• Vestibular Neuronitis

Citations

1. Victor M, Ropper AH (2001). Benign positional vertigo (of Bárány) section of Deafness, dizziness, and disorders of equilibrium. In M Victor, ed., Adams and Victor's Principles of Neurology, 7th ed., pp. 321–322. New York: McGraw-Hill.

2. Koelliker P, et al. (2001). Benign paroxysmal positional vertigo: Diagnosis and treatment in the emergency department—A review of the literature and discussion of canalith-repositioning maneuvers. Annals of Emergency Medicine, 37(4): 392–398.

Other Works Consulted

• Frohman EM (2002). Evaluation of the dizzy patient. In DC Dale, DD Federman, eds., Scientific American Medicine, vol. 3, part 11, chap. 1. New York: Scientific American.

• Hilton M, Pinder D (2004). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews (2). Oxford: Update Software.

• Von Brevern M, et al. (2004). Migrainous vertigo presenting as episodic positional vertigo. Neurology, 62(3): 469–472.

Author:	Cynthia Tank	Last Updated February 24, 2005
Medical Review:	Adam Husney, MD - Family Medicine Colin Chalk, MD, CM, FRCPC - Neurology
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