How do you differentiate and treat Benign Paroxysmal Positional Vertigo (BPPV) versus dizziness?

Differentiating and Treating BPPV versus Other Causes of Dizziness

BPPV is diagnosed by brief (<1 minute) episodes of vertigo triggered by specific head position changes, confirmed with the Dix-Hallpike maneuver, and treated immediately with canalith repositioning procedures (Epley or Semont maneuvers) which have 70-90% success rates after a single session. 1, 2

Key Diagnostic Features of BPPV

BPPV fits the "triggered episodic vestibular syndrome" pattern with these defining characteristics: 1

• Episodes last <1 minute (not hours or days) 1, 3
• Obligate positional trigger - specifically rolling over in bed, looking up, or bending forward 3
• No hearing loss, tinnitus, or aural fullness (distinguishes from Menière's disease) 1
• No constant severe dizziness unaffected by position 4
• Does not cause fainting 4

The two most reliable predictive questions are: 3

• Does your dizziness last less than 1 minute? (Sensitivity 43%, Specificity 75%)
• Is your dizziness provoked by rolling over in bed? (Sensitivity 81%, Specificity 68%)

Differentiating BPPV from Other Vestibular Syndromes

The American Academy of Otolaryngology-Head and Neck Surgery categorizes dizziness into four distinct syndromes based on timing and triggers: 1

Acute Vestibular Syndrome (Days to Weeks)

• Vestibular neuritis/labyrinthitis: Continuous severe vertigo lasting days with profound nausea, vomiting, and intolerance to head motion 1, 2, 5
• Stroke: More sudden onset than vestibular neuritis; 10% of cerebellar strokes mimic peripheral vestibular processes 4

Spontaneous Episodic Vestibular Syndrome (Minutes to Hours, Not Triggered)

• Menière's disease: Episodes lasting hours with fluctuating hearing loss, tinnitus, and aural fullness 1, 5
• Vestibular migraine: Episodes lasting 5 minutes to 72 hours with migraine features (photophobia, headache); lifetime prevalence 3.2% 4, 5
• Vertebrobasilar insufficiency: Episodes <30 minutes, no hearing loss, may precede stroke by weeks 1, 5

Triggered Episodic Vestibular Syndrome (BPPV's Category)

• Superior canal dehiscence: Triggered by pressure changes (Valsalva), not position changes; may have conductive hearing loss 1
• Perilymph fistula: Triggered by pressure; may follow ear surgery or occur spontaneously 1, 5

Chronic Vestibular Syndrome (Weeks to Months)

• Cervical vertigo: Triggered by head rotation relative to body while upright (not relative to gravity) 1, 5
• Postural hypotension: Provoked by moving from supine to upright position 1, 5
• Medication side effects: Anticonvulsants, antihypertensives, cardiovascular medications 1, 5
• Psychological disorders: Panic, anxiety, agoraphobia causing lightheadedness 1, 5

Critical Red Flags Suggesting Central (Not BPPV) Pathology

Immediately consider neurologic causes if any of these nystagmus patterns are present: 1, 4

• Downbeating nystagmus on Dix-Hallpike (especially without torsional component) 1, 4
• Direction-changing nystagmus without head position changes (periodic alternating nystagmus) 1, 5
• Gaze-evoked, direction-switching nystagmus (beats right with right gaze, left with left gaze) 1
• Baseline nystagmus without provocative maneuvers 1
• Nystagmus that doesn't lessen with visual fixation 5

Diagnostic Testing Algorithm

Step 1: Perform Dix-Hallpike Maneuver

• For posterior canal BPPV (85-95% of cases): Look for upbeating-torsional nystagmus 4, 2, 6
• Positive test confirms diagnosis; no imaging required 2, 7

Step 2: If Dix-Hallpike Negative, Perform Supine Roll Test

• For horizontal canal BPPV (5-15% of cases): Look for direction-changing horizontal nystagmus 1, 2

Step 3: If Both Tests Negative

• Reconsider diagnosis using vestibular syndrome framework above 1
• Consider audiometry if hearing symptoms present 2
• Brain imaging only if red flags present 7

Treatment of BPPV

Perform canalith repositioning immediately in the emergency department or office - do not prescribe vestibular suppressants or order imaging: 7

Posterior Canal BPPV (85-95% of cases)

• Epley maneuver or Semont maneuver (equally effective, level 1 evidence) 2, 8, 7
• Success rate: 70-90% after single treatment 2
• Choice of maneuver based on clinician preference or patient mobility restrictions 8

Horizontal Canal BPPV (5-15% of cases)

• Gufoni maneuver (level 1 evidence) 8

Post-Treatment Expectations

• 61% of patients experience residual dizziness after successful repositioning 9
• Two types: continuous lightheadedness or short-lasting unsteadiness with movement 9
• Resolves within 3 months without specific treatment (median 10 days) 9
• Early treatment reduces residual dizziness incidence 9

When Treatment Fails

• Recurrence rate: 15% 2
• Post-traumatic BPPV requires more treatments (67% vs 14% for idiopathic) 1, 2
• Consider multiple canal involvement 2, 8
• Consider associated comorbidities: migraine, persistent postural perceptual dizziness 8
• Evaluate for low vitamin D (risk factor for recurrence) 8
• Failure to respond should raise concern the diagnosis is not BPPV 1

Common Pitfalls to Avoid

• Do not order brain imaging for typical BPPV - this increases cost, radiation exposure, and ED length of stay without benefit 7
• Do not prescribe meclizine or other vestibular suppressants - these are ineffective for BPPV and cause side effects 7
• Do not miss post-traumatic BPPV - elicit trauma history as it may be bilateral and more refractory 1, 2
• Do not assume single diagnosis - BPPV can coexist with Menière's disease, vestibular neuritis, or multiple sclerosis 1
• In elderly patients, do not expect only vertigo - they may describe instability or lightheadedness rather than spinning 3