Is Benign Paroxysmal Positional Vertigo (BPPV) the most common cause of vertigo?

BPPV is the Most Common Cause of Vertigo

Yes, Benign Paroxysmal Positional Vertigo (BPPV) is definitively the most common cause of vertigo, as confirmed by clinical practice guidelines. 1

Epidemiology and Prevalence

• BPPV is the most common inner ear problem and the leading cause of vertigo or false sense of spinning 1
• It is very common in the general population, with higher prevalence in older adults 1
• Many people will experience BPPV at some point in their lives 1
• In non-specialty clinical settings, BPPV accounts for approximately 42% of vertigo cases, followed by vestibular neuritis (41%), Meniere's disease (10%), and vascular causes (3%) 1
• In subspecialty settings, the distribution may differ with Meniere's disease at 43%, followed by BPPV (23%) and vestibular neuritis (26%) 1

Pathophysiology

• BPPV occurs when calcium carbonate crystals (otoconia) become dislodged from their normal location in the utricle and migrate into the semicircular canals 1
• As these crystals move within the canals during head movements, they create false signals of motion, resulting in vertigo 1
• Posterior canal BPPV is most common (85-95% of cases), followed by lateral/horizontal canal BPPV (5-15% of cases) 1
• Anterior canal BPPV is rare, accounting for approximately 1% of cases 2

Clinical Presentation

• BPPV is characterized by brief episodes of vertigo triggered by specific changes in head position 1
• Typical symptoms include:
  • Distinct triggered spells of vertigo or spinning sensations 1
  • Nausea and sometimes vomiting 1
  • Sense of disorientation in space 1
  • Instability or imbalance 1
• Episodes typically last seconds to minutes and are provoked by activities such as lying down, rolling over in bed, looking up, or bending over 1, 3
• The first attack often occurs in bed or upon getting up 3

Diagnosis

• Diagnosis is primarily clinical, based on history and specific positional testing 1
• The Dix-Hallpike maneuver is used to diagnose posterior canal BPPV, while the supine roll test identifies lateral canal BPPV 1, 4
• Imaging studies are not routinely indicated for typical BPPV 4
• Failure to perform appropriate diagnostic maneuvers may lead to misdiagnosis and unnecessary testing 4, 5

Differential Diagnosis

• Other causes of vertigo that must be distinguished from BPPV include:
  • Vestibular migraine (migraine-associated vertigo) 1
  • Meniere's disease 1
  • Vestibular neuritis 1
  • Brainstem and cerebellar stroke or TIAs 1
  • Multiple sclerosis and other intracranial disorders 1

Treatment

• Canalith repositioning procedures (CRPs) are highly effective for BPPV, with success rates around 80% with only 1-3 treatments 1
• The specific CRP depends on the canal involved:
  • Epley maneuver for posterior canal BPPV 2
  • Gufoni, Lempert, or Vannucchi-Asprella maneuvers for lateral canal BPPV 2
  • Yacovino maneuver for anterior canal BPPV 2
• Post-maneuver activity restrictions do not appear to improve treatment efficacy 6
• Medications are not typically used for BPPV treatment except for immediate relief of symptoms like nausea 1

Clinical Pitfalls

• BPPV is often underdiagnosed or misdiagnosed despite being the most common cause of peripheral vertigo 1
• Failure to perform both the Dix-Hallpike and supine roll tests may result in missed diagnoses, particularly for lateral canal BPPV 2
• Atypical nystagmus patterns (e.g., down-beating nystagmus without torsional component) or failure to respond to appropriate treatment should raise concern for central causes 1
• Special care should be taken when performing diagnostic maneuvers in patients with cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, or other conditions affecting neck mobility 1