Diaphoresis and BPPV
Diaphoresis (excessive sweating) is not a recognized symptom of benign paroxysmal positional vertigo (BPPV) according to the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines.
Established Symptoms of BPPV
The official clinical practice guidelines clearly delineate what symptoms are associated with BPPV 1:
- Vertigo/spinning sensations triggered by specific head position changes 1
- Nausea (sometimes with vomiting) 1
- Severe disorientation in space 1
- Instability or imbalance 1
- Dizziness (particularly in elderly patients) 1
What BPPV Does NOT Cause
The guidelines explicitly state that BPPV does not cause 1:
- Constant severe dizziness unaffected by position
- Hearing loss
- Fainting/syncope
Notably absent from all guideline documentation is any mention of diaphoresis, sweating, or autonomic symptoms as features of BPPV 1.
Clinical Implications
When Diaphoresis Should Raise Concern
If a patient presents with positional vertigo plus diaphoresis, consider alternative or concurrent diagnoses 1:
- Central nervous system pathology (brainstem or cerebellar stroke) - may present with autonomic symptoms including diaphoresis 1
- Vertebrobasilar insufficiency - can cause vertigo with autonomic features 1
- Vestibular migraine - may have associated autonomic symptoms 1
- Panic disorder or anxiety - commonly presents with diaphoresis and dizziness 1
Red Flags Requiring Further Evaluation
The presence of diaphoresis with vertigo warrants investigation for 1:
- Neurologic signs: dysarthria, dysmetria, dysphagia, sensory/motor deficits, Horner's syndrome
- Atypical nystagmus patterns: downbeating without torsional component, direction-changing without head position change, gaze-evoked nystagmus
- Failure to respond to canalith repositioning maneuvers
Chronic BPPV Considerations
While one observational study of chronic BPPV patients reported various symptoms including pain, fatigue, and visual disturbances 2, diaphoresis was not among the reported symptoms even in this complex patient population. This further supports that sweating is not a feature of BPPV, even in chronic or complicated cases.
Bottom Line
If diaphoresis is present with positional vertigo, do not attribute it to BPPV 1. Perform a thorough neurologic examination and consider neuroimaging to exclude central causes of vertigo, particularly posterior circulation stroke 1.