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Last updated: 2/20/2024
Years published: 1987, 1989, 1998, 2000, 2011, 2014, 2017, 2020, 2024
NORD gratefully acknowledges Terry D. Fife, MD, University of Arizona College of Medicine, Barrow Neurological Institute, for the assistance in the preparation of this report.
Summary
Benign paroxysmal position vertigo (BPPV) is a disorder characterized by brief, recurrent bouts of vertigo. Vertigo is a sensation of spinning, whirling or turning. Individuals often feel as if the room is moving or spinning, and they can lose their balance and have difficulty standing or walking. During the vertigo spells, affected individuals often have abnormal eye movements as well (nystagmus). BPPV is most often triggered by changes in head position. The severity of the disorder varies. In some people, it only causes mild symptoms, while in others it can potentially cause more severe, even debilitating symptoms. BPPV may disappear but sometimes it persists recurrently for many months. Most affected individuals can be easily and effectively treated by non-invasive methods such as canalith (or canalolith) repositioning maneuvers or procedures. However, BPPV may recur even after being effectively treated. BPPV is thought to be caused by the displacement of small calcium carbonate crystals within the inner ear. These tiny crystals originate from the gravity and acceleration sensing structures and become inappropriately located in one of three semicircular canals, which are tiny, interconnected, looped tubes that serve to detect movements of the head and play a role in helping the body maintain balance. The exact, underlying cause of this displacement is not always known (idiopathic). Recurrences are possible because additional calcium can become dislodged. The treatment maneuvers move the calcium particles back to the main vestibule, the chamber from which they originated. This stops the vertigo. However, the maneuvers do not prevent the shedding of additional calcium crystals in the future.
Introduction
BPPV has been identified as a clinical entity since the late 1800s. The term benign means that the disorder is not progressive and is not considered serious. Although labeled benign, BPPV can disrupt a personโs daily activities and affect quality of life. The term paroxysmal means that episodes arise suddenly and often unpredictably. The term positional means the disorder is contingent on a change of the position of the head. BPPV is one of the most common causes of vertigo.
The onset of an episode of BPPV is usually sudden following changes in head position. Often, ordinary movements such as turning over on oneโs side, lying down, looking up, stooping or bending over can cause an episode. The severity of the disorder can vary greatly from one person to another. Factors that may affect the severity include the speed of head movement, the volume of calcium crystals that are moved and a personโs innate sensitivity to motion. For some people, only a slight positional change of the head can cause symptoms. This extreme sensitivity can cause near frequent sensations of tilting or dizziness. In other individuals, the disorder may only produce mild symptoms despite a rapid change of head position. In some affected individuals, symptoms may only be caused by very precise, specific movements. The duration of symptoms of BPPV may also vary and can potentially persist recurrently for days, weeks or months or become recurrent over many years.
Vertigo in individuals with BPPV usually lasts less than 30 seconds. Vertigo can lead to unsteadiness and a loss of balance. Additional symptoms can develop including lightheadedness, dizziness, nausea, vomiting and blurred vision. Nausea or a feeling of queasiness can persist for a short time even after the sensation of vertigo has passed.
A common associated finding with BPPV is nystagmus, an eye movement disorder characterized by rapid, involuntary movements of the eye. The eyes may be described as jumping or twitching in certain directions. Nystagmus associated with BPPV is fatigable meaning that if one repeats the position change that induced the original vertigo and nystagmus, after time nystagmus lessens in severity.
The type of nystagmus, defined by the direction of the abnormal eye movements, depends upon which of the three semicircular canals of the inner ear is involved. The three canals are known as the posterior, horizontal (lateral) and anterior (superior) canals. Thus, BPPV can be classified as posterior canal BPPV, horizontal canal BPPV or anterior canal BPPV based on the specific canal involved. About 80% of cases of BPPV involve the posterior canal.
In some patients, the exact underlying cause of BPPV is unknown. Researchers think that most cases of BPPV are caused by abnormalities affecting the inner ear. The inner ear contains the cochlea, which converts sound pressure from the outer ear into nerve impulses that are sent to the brain via the auditory canal. The inner ear also contains a vestibular apparatus for balance that includes the semicircular canals. Fluid moves through these canals enabling the brain to detect turning movements of the head.
Two additional structures found in the inner ear are the utricle and saccule (otolith organs). The utricle and saccule are fluid-filled sacs or cavities that detect acceleration movements of the head including gravity. The utricle and saccule contain small calcium carbonate crystals. For unknown reasons, in individuals with BPPV these crystals may partially erode, and small pieces of the crystals fall off and end up in one of the adjoining semicircular canals. Within the canals, these crystals may stimulate specialized sensing organ of the inner ear tubes that is called the cupula. This results in the body being sensitive to certain head position changes that normally would not cause dizziness. Basically, the brain is sent powerful asymmetric nerve signals that resemble the kind of asymmetry associated with spinning. This gives a patient the same sensation that would occur with spinning.
Two specific theories proposed regarding the underlying cause of BPPV are the canalithiasis and cupulolithiasis theories. These proposed mechanisms are not mutually exclusive and there is scientific evidence that both occur, but that canalithiasis is more common than cupulolithiasis. Canalithiasis refers to calcium crystals that are freely mobile within the semicircular canals and, whenever the head changes position, these crystals move through the canal. As these crystals move, they are thought to drag the fluid within the canals, known as endolymph, behind them. As the endolymph moves through the canals, it stimulates the hair cells of the cupula causing vertigo and nystagmus. When the head is not moving, the crystals (and therefore the endolymph) do not move as well. Consequently, there is no stimulation of the cupula and no associated vertigo or nystagmus. It is thought that these crystals eventually dissolve or fall back into the vestibule (the cavity at the entrance to one of the canals). Canalithiasis appears to best explain most cases of BPPV.
Cupulolithiasis refers to crystals that have become stuck or attached to the cupula in one of the three semicircular canals, usually the posterior canal. BPPV caused by cupulolithiasis is thought to account for the more persistent cases of BPPV that do not respond as well to positioning treatments.
Neither the canalithiasis nor the cupulolithiasis theories address why the crystals become dislodged. There are many different theories as to what conditions can cause crystals to become dislodged and enter the semicircular canals. Such conditions include head trauma, surgery, chronic middle ear infections (otitis media), a severe cold or infection or vestibular neuritis. There are some possible associations with osteoporosis.
Additional factors that may predispose individuals to BPPV include alcoholism, inactivity, age, and certain central nervous system disorders. In many cases, no such precipitating cause can be identified.
The lifetime prevalence of BPPV is about 2.4% and other estimates range from 10-64 per 100,000 people in the general population. However, many physicians think that the true frequency may be higher. BPPV most often affects older adults with a peak age of onset in the sixth decade. The disorder may affect individuals of any age but is quite uncommon in those under 20 years of age. Females are thought to be affected at least twice as often as males.
A diagnosis of BPPV is based upon identification of characteristic symptoms, a detailed patient history and a thorough clinical evaluation. Affected individuals usually have a history of episodes of vertigo.
Clinical Testing and Work-Up
Affected individuals will undergo a Dix-Hallpike test. During this test, the person sits down with legs extended on an examination table. The doctor will rotate the head approximately 30 to 45 degrees and then help the person quickly lie on their back (supine position). In individuals with BPPV, this will prompt a characteristic episode of nystagmus and/or vertigo. The timing and appearance of the eye movements will help a physician determine the cause of vertigo. The Dix-Hallpike test can differentiate vertigo caused by a problem in the brain from vertigo caused by a problem in the inner ear. The specific pattern of nystagmus will tell a physician which of the three semicircular canals of the inner ear is involved in an individual case.
When the diagnosis is in doubt, affected individuals may undergo a test such as magnetic resonance imaging (MRI) to rule out other conditions. An MRI uses a magnetic field and radio waves to produce cross-sectional images of organs and bodily tissues such as in the brain or ear.
In some cases, a physician may use a test called a videonystagmogram (VNG), which records the voluntary and involuntary movements of the eyes. During this exam, goggles with cameras are placed over the eyes (VNG). Both techniques record eye movements following different stimuli such as staring at a light, moving the head to different positions and stimulating the inner ear and nearby tissue, usually by cold or warm water (or air). Another test sometimes used is video head impulse testing (vHIT) which tests the integrity of the vestibular function in each semicircular canal of the inner ear on both sides. The information can then be analyzed by a computer, and this can determine if there is a disturbance in the normal functioning of the inner ear balance.
Treatment
Individuals with BPPV may be treated with canalith repositioning procedures, in which the head is put through a series of specific movements designed to shift the crystals (otoliths) out of the semicircular canals and back into the vestibule. Once the crystals are back in the vestibule, they are usually reabsorbed in a matter of days. The maneuvers may need to be repeated. Different maneuvers are required depending upon which of the three semicircular canals is involved. Canalith repositioning procedures are often highly effective in treating BPPV, although the condition can recur often within one year. Canalith repositioning procedures are initially performed at a physicianโs office, but patients may be taught the maneuvers in order to perform them at home. During therapy, crystals may occasionally move from one semicircular canal to another, which is referred to as canal switch.
The Epley maneuver is a common canalith repositioning procedure. The Epley maneuver is a five-position cycle that is repeated usually once or until no signs of nystagmus are observed. Patients are placed in a sitting position on an examination table with their head turned 45 degrees toward the affected ear. Patients are then tilted back onto the table with their head hanging off the end. The head is then slowly rotated toward the unaffected ear. Patients are then rolled onto their side and the head is rotated back toward the affected ear. The patient is then brought back to a sitting position. Canalith repositioning procedures like the Epley maneuver are relatively simple, noninvasive and effective therapy for individuals with BPPV. Treatment for right sided typical BPPV can be viewed on YouTube at: http://www.youtube.com/watch?v=ZqokxZRbJfw .
Other canal repositioning procedures used to treat individuals with BPPV include the Semont liberatory maneuver and for the less common horizontal canal variant of BPPV, the Lempert or Gufoni maneuver. These maneuvers may have slight variations as well and some of these treatments may be viewed on YouTube at: http://www.youtube.com/watch?v=hq-IQWSrAtM.
Some affected individuals may be referred for vestibular rehabilitation therapy (VRT). VRT is the use of specific exercises that are designed to compensate for inner ear deficiencies. While this technique may coincidentally improve BPPV, it is really intended to promote adaptation by the brain to loss of balance function related to inner ear on one side. A physical or occupational therapist will develop a treatment plan tailored to an individual based upon a thorough examination. Basically, affected individuals will perform a series of exercises or postures that over time will lessen their symptoms. Initially, the exercises may temporarily worsen symptoms. However, if affected individuals persist with their instructions, VRT often leads to a decrease in symptom severity or complete disappearance of symptoms. In some people, no other therapy is necessary.
Some individuals with BPPV may opt for watchful waiting, meaning not treating the condition and waiting for symptoms to spontaneously resolve. This is the best option for those with recent cervical spine fractures that must remain immobilized while healing, for example. For most people, however, there seems little point in waiting to be treated since treatment is quick and easy. Furthermore, symptom resolution can take weeks or months in some individuals.
Some affected individuals may receive vestibular suppressant medications (e.g., meclizine or diazepam) that may help relieve certain symptoms of BPPV such as the spinning sensation or nausea. However, drug therapy for BPPV itself is generally ineffective and usually not recommended because canalith repositioning maneuvers are so effective.
In rare cases, individuals with BPPV may be treated with surgery. The frequency of surgery as a treatment for BPPV has dropped in recent years. Surgery for BPPV is reserved for individuals who fail to respond to less invasive treatment options and for people with symptoms that are recurrent and problematic (intractable BPPV). The most common procedure used is plugging (occluding) the posterior semicircular canal to prevent crystals from causing deflection and stimulation of the cupula. Canal plugging is used more often in the rare cases that require surgical intervention. Surgical therapy is not considered for BPPV except as a last resort.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. Government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
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Some current clinical trials also are posted on the following page on the NORD website: https://rarediseases.org/living-with-a-rare-disease/find-clinical-trials/
For information about clinical trials sponsored by private sources, contact: www.centerwatch.com
For information about clinical trials conducted in Europe, contact: https://www.clinicaltrialsregister.eu/
JOURNAL ARTICLES
Kim HJ, Park J, Kim JS. Update on benign paroxysmal positional vertigo. J Neurol 2021;268(5):1995-2000.
Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3 suppl):S1-S47.
von Brevern M, Bertholon P, Brandt T, Fife T, et al. Benign paroxysmal positional vertigo: diagnostic criteria. J Vestib Res 2015;25(3-4):105-117.
Imai T, Inohara H. Benign paroxysmal positional vertigo. Auris Nasus Larynx. 2022 Oct;49(5):737-747.
Cohen HS, Sangi-Haghpevkar H. Canalith repositioning variations for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2010;143:405-412. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925299/pdf/nihms204567.pdf
Fife TD. Benign paroxysmal positional vertigo. Semin Neurol. 2009;29(5):500-508. doi:10.1055/s-0029-1241041
Fife TD, Iverson J, Lempert T, et al. Practice parameters: therapies for benign paroxysmal positional vertigo (an evidence-based review: report of the Quarterly Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70:2067-2074.
INTERNET
Li JC, Meyers AD. Benign paroxysmal positional vertigo. Medscape. Updated Jan 14, 2022. Available at: https://emedicine.medscape.com/article/884261-treatment Accessed Feb 8, 2024.
Benign Paroxysmal Positional Vertigo. Vestibular Disorders Association. Updated: November 2022. https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/benign-paroxysmal-positional-vertigo-bppv/ Accessed Feb 8, 2024.
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