What symptoms are required to diagnose Benign Paroxysmal Positional Vertigo (BPPV)?

Diagnostic Criteria for Benign Paroxysmal Positional Vertigo (BPPV)

To diagnose BPPV, clinicians must observe vertigo associated with characteristic nystagmus provoked by the Dix-Hallpike maneuver, with a latency period followed by resolution of symptoms and nystagmus within 60 seconds from onset.1

History Findings

The historical features that suggest BPPV include:

• Brief episodes of vertigo triggered by specific head movements relative to gravity 1
• Episodes typically last less than 60 seconds 1
• Common triggers include:
  • Rolling over in bed
  • Tilting head upward (looking up at shelves)
  • Bending forward (tying shoes)
  • Getting in or out of bed 1
• Patients often report modifying movements to avoid triggering episodes 1

While rotational/spinning vertigo is classic, patients may alternatively report:

• Lightheadedness
• Dizziness
• Nausea
• Feeling "off balance" 1

Approximately 50% of patients report subjective imbalance between episodes 1.

Physical Examination Requirements

The diagnosis of posterior canal BPPV requires ALL of the following during the Dix-Hallpike maneuver:

1. Provoked vertigo with characteristic nystagmus during the Dix-Hallpike test 1, 2
2. Latency period between completion of the maneuver and onset of vertigo/nystagmus (typically 5-20 seconds, rarely up to 1 minute) 1, 2
3. Limited duration - symptoms and nystagmus increase and then resolve within 60 seconds from onset 1, 2

Proper Execution of Dix-Hallpike Maneuver

The Dix-Hallpike maneuver must be performed correctly:

1. Patient begins in seated position
2. Examiner rotates patient's head 45 degrees to one side
3. Patient is quickly moved to supine position with head hanging 20 degrees off the examination table
4. Examiner observes for nystagmus and asks about vertigo symptoms
5. Procedure is repeated for the opposite side 1, 2

Nystagmus Characteristics

For posterior canal BPPV (most common type):

• Torsional (rotatory), upbeating nystagmus 2
• Has a latency period of 5-20 seconds
• Resolves within 60 seconds
• Direction of nystagmus helps identify the affected canal 2

Common Diagnostic Pitfalls

• Failure to perform the Dix-Hallpike maneuver on both sides 2
• Misinterpreting nystagmus direction (confusing lateral canal BPPV with posterior canal BPPV) 2
• Not recognizing that BPPV can affect multiple canals simultaneously 2, 3
• Missing BPPV with longer latency periods (up to 1 minute in some cases) 1, 3
• Attributing symptoms to other conditions when patients present with atypical symptoms like neck pain, headache, or nautical vertigo rather than classic rotatory vertigo 3

Differential Diagnosis Considerations

BPPV must be distinguished from:

• Migraine-associated vertigo (includes headache, photophobia, phonophobia) 1
• Vertebrobasilar insufficiency (vertigo episodes <30 minutes, no hearing loss) 1
• Ménière's disease 2
• Vestibular neuritis 2
• Posterior circulation stroke (can present with isolated vertigo in up to 25% of cases) 2
• Cervical vertigo (triggered by head rotation relative to body while upright) 1
• Postural hypotension (provoked by moving from supine to upright) 1

Key Points to Remember

• BPPV does not cause constant severe dizziness unaffected by position 1
• BPPV does not affect hearing or cause fainting 1
• In up to one-third of cases with atypical histories, Dix-Hallpike testing will still reveal characteristic nystagmus 1
• The natural course of BPPV is to become less severe over time 1
• Failure to respond to appropriate repositioning maneuvers should raise concern for alternative diagnoses 1

By following these diagnostic criteria strictly, clinicians can accurately diagnose BPPV and distinguish it from other vestibular and neurological disorders that may require different management approaches.