What Is BPPV?

BPPV or Benign Paroxysmal Positional Vertigo is one of the most common disorders of the inner ear that results in vertigo. It is due to particles (crystals, otoliths,”ear rocks”) that have collected in the fluid filled balance canals of the inner ear. These particles, made of calcium, float in the fluid and will occasionally touch a sensitive area resulting in the sensation of vertigo. The name of this disorder is derived from the fact that BPPV is Benign (not life threatening), Paroxysmal (dizziness occurs suddenly and briefly), Positional (dizziness occurs with particular head positions) and causes Vertigo (sensation of spinning). BPPV is a common cause of dizziness. About 20% of all dizziness is due to BPPV. In older people, half of the patients with dizziness may have BPPV.


The symptoms can vary in each person and include dizziness or vertigo, lightheadedness, imbalance, and sometimes nausea and vomiting with head movements. The symptoms are almost always precipitated by a positional change of the head or body. Getting into or out of bed, or rolling over in bed are common “problem motions”. Some people will feel dizzy and unsteady when they tilt their heads back such as looking up, brushing their teeth, washing their hair, instilling eye drops, or checking the “blind spots” while driving. Although many people feel normal when not in a “problem” position, some do have a sensation of imbalance.

BPPV has often been described as “self-limited” because symptoms often subside or disappear within six months of onset. Symptoms tend to wax and wane. The symptoms can last for days or occasionally months.


The most common cause of BPPV in people under age 50 is head injury. It is more common in older people, commonly due to degeneration of the balance system of the inner ear. A viral upper respiratory infection or allergy flare up may also play a role. It also occurs commonly in people with Meniere’s disease and otosclerosis and after surgical and dental procedures. Minor stroke of the blood vessels supplying inner ear or a tumor of the inner ear are rare causes of BPPV. However, in perhaps half of all cases, BPPV is called “idiopathic”, which means it occurs for no known reason.


Your doctor will make the diagnosis based on your symptoms, physical examination and the results of your hearing and balance tests. During medical evaluation, Dix Hallpike test will be performed which helps to make the diagnosis of BPPV. During this test, the head is turned and the lies down quickly from a sitting position to hang the head at a 45 degree angle over the side of the table or bed. This is then repeated with the head turned to the other side. If there is a crystal, these movements cause a quick burst of nystagmus (jumping of the eyes) thus confirming the diagnosis of BPPV. Occasionally other tests may be required. A video nystagmography test (VNG) test may be needed to look for the characteristic eye movements and other possible causes of vertigo. An MRI scan would be performed if there is any possibility of a stroke or brain tumor. Although rare, it is possible to have BPPV in both ears, which may make the diagnosis and treatment more challenging.


Motion sickness medications (Meclizine, Dramamine, Bonine etc) are rarely effective and often worsen balance. These should be discontinued 48 hours prior to your doctor’s appointment for the evaluation of dizziness as they may interfere with the physical findings. Once the diagnosis of BPPV is confirmed, an in office treatment called an “Epley maneuver” is performed. This is effective in treating over 90% of cases. Other maneuvers exist to treat resistant or more complicated cases. A surgical procedure called “posterior semicircular canal occlusion” may be used to treat BPPV in the rare person where maneuvers fail.


The Epley maneuver (also called the particle repositioning or canalith repositioning procedure) involves sequential movement of the head through four positions while lying down. A hand held massager is applied to the bone behind the ear during these head movements. The procedure t moves the crystals from the balance canals back to their normal location where they do not cause any vertigo. The entire procedure takes about 10 minutes. It is best to have someone drive you to your appointment as you may feel dizzy after the maneuver. You will be given a cervical collar and certain instructions to follow that help in making this treatment a success. It is best to come to your appointment on an empty stomach. The maneuver can very rarely cause vertigo to worsen temporarily.


To increase the success of the Epley maneuver you will be asked to:
Wear the cervical collar for the next 7 days during the daytime

You will take it off for napping or sleeping

For the first 2 nights, sleep upright or at a 45 degree angle, in a recliner or in your bed with pillows behind your back.

From 3rd night onwards, sleep on your back or on the opposite (unaffected) ear.

You will be seen in one week for a follow up appointment to check for the resolution of vertigo

This treatment has a cure rate of 80% and repeat treatments may be necessary in the other 20% of the symptomatic patients. In rare cases, if repeat treatments fail, a surgical procedure called posterior semicircular canal occlusion can be performed.


Some people may feel lightheaded, imbalanced or “woozy” even after the treatment has been successful. These patients are put on a regimen of daily at home head and neck exercises for rehabilitation of the balance system. BPPV often recurs, in 30% within one year and 50% within five years.

Any vertigo accompanied by a change in hearing, blurring or double vision, severe headaches, numbness or tingling of body with difficulty speaking and swallowing, or loss of consciousness is an indication of a more serious medical condition and should be evaluated urgently.

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