Why do I keep getting recurrent Benign Paroxysmal Positional Vertigo (BPPV)?

Why You Keep Getting Recurrent BPPV

Recurrent BPPV is common and expected—affecting approximately 15% of patients per year, with rates reaching 27-50% over 5 years—and when it keeps recurring, you likely have underlying vestibular dysfunction that needs investigation. 1

Understanding Your Recurrence Risk

BPPV recurrence is the rule, not the exception. The natural history shows:

• 5-13.5% recurrence at 6 months after successful treatment 1
• 10-18% recurrence at 1 year 1
• 27-50% recurrence by 5 years, with an overall rate of approximately 15% per year 1, 2
• 50% of recurrences occur within the first 6 months after initial resolution 2

Post-traumatic BPPV has even higher recurrence rates than idiopathic cases 1

Why Your BPPV Keeps Coming Back

Primary Reason: Underlying Vestibular Pathology

25-50% of patients with recurrent BPPV have additional vestibular disorders that weren't identified during initial evaluation 1. This is the most important factor distinguishing recurrent from non-recurrent cases.

Specific findings in recurrent BPPV patients:

• 50% have abnormalities on vestibular evoked myogenic potential testing (cervical or ocular), compared to only 15% in non-recurrent BPPV 1
• 31-53% have additional otopathology or vestibulopathy when thoroughly evaluated at specialty centers 1
• These abnormalities suggest more complex otolith dysfunction beyond simple canalithiasis 1

Associated Vestibular Disorders

Common conditions that coexist with recurrent BPPV include: 1

• Menière's disease
• Viral vestibular neuritis
• Labyrinthitis

When these conditions are present, canalith repositioning procedures still resolve the positional nystagmus effectively, but complete symptom resolution drops dramatically—from 86% in isolated BPPV to only 37% when additional vestibular pathology exists 1

Secondary Causes Are More Common in Recurrent Cases

Trauma and other secondary causes occur much more frequently in recurrent and persistent BPPV compared to typical single-episode BPPV 3

Complex BPPV patterns predict recurrence:

• Multi-canal BPPV shows significantly greater tendency to recur and recurs earlier (log-rank p=0.024) 2
• Anterior canal BPPV recurs more frequently and earlier than posterior canal (log-rank p=0.029) 2
• Requiring multiple maneuvers to resolve initial episode predicts earlier recurrence (log-rank p=0.023) 2

Important Pattern Recognition

Each recurrence is usually different from the previous episode. Only 24% of patients experience recurrence in the same canal on the same side 4. This means:

• At least 70% of recurrences affect a different side and/or different canal than the primary episode 2
• The proportions of involved canals remain similar across recurrences, but individual patients don't follow predictable patterns 4
• When BPPV recurs, every canal on both sides must be investigated—it's the BPPV syndrome that recurs, not a specific canal problem 2

What You Should Do About Recurrent BPPV

Get Comprehensive Vestibular Testing

The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends vestibular function testing for patients with frequent recurrences of BPPV. 1

Testing is warranted when you have: 1

1. Frequent recurrences of BPPV
2. Failed or repeatedly failed response to canalith repositioning
3. Atypical nystagmus patterns
4. Suspected additional vestibular pathology

This testing can identify the underlying vestibular dysfunction driving your recurrences and lead to additional targeted management 1

Consider Neurological Evaluation

If symptoms are atypical or refractory to treatment, additional evaluation is needed to exclude CNS disorders that can masquerade as BPPV 1. This includes:

• Thorough neurological examination
• MRI of brain and posterior fossa if symptoms persist after 2-3 attempted maneuvers 1
• Evaluation for associated auditory or neurological symptoms 1

3% of treatment-refractory cases have CNS disorders explaining the failure 1

Common Pitfalls to Avoid

Don't assume each recurrence will be the same type. Since 76% of recurrences involve different canals or sides, self-treatment based on your previous episode has limited efficacy 4. However, web-based diagnostic systems that help you identify the current type before self-treatment are effective, with 72.4% resolution rates 5

Don't ignore persistent symptoms after successful repositioning. If you have ongoing imbalance, hearing changes, or non-positional vertigo after the positional component resolves, this indicates underlying vestibular pathology requiring further evaluation 1

Don't delay seeking treatment. Recurrent BPPV significantly increases fall risk and negatively affects quality of life, particularly in elderly patients 1