Is Vomiting Normal in BPPV?
Yes, nausea and vomiting are recognized as normal autonomic symptoms that can occur with BPPV, though they are not present in all patients and typically resolve when the vertigo episode subsides. 1, 2, 3
Understanding Nausea and Vomiting in BPPV
Common Autonomic Symptoms
Nausea and occasional vomiting are well-established symptoms of BPPV, occurring as part of the autonomic response to the intense vertigo triggered by position changes. 3
The American Academy of Otolaryngology-Head and Neck Surgery explicitly recognizes nausea (sometimes with vomiting) as a common symptom in their clinical practice guidelines. 3
These autonomic symptoms are typically brief and self-limiting, corresponding to the duration of the vertigo episode (typically 10-60 seconds). 2
Clinical Context and Severity
Patients should be informed that nausea, occasional vomiting, and/or a sense of falling may arise during canalith repositioning procedures (CRP), such as the Epley maneuver. 1
Some patients experience severe nausea and vomiting during diagnostic testing (Dix-Hallpike maneuver) or treatment, which may require antiemetic prophylaxis 30-60 minutes prior to performing repositioning maneuvers. 1
In research studies, approximately 21.6% of patients reported nausea and vomiting as initial BPPV symptoms. 4
When to Consider Alternative Diagnoses
Red Flags for Persistent Symptoms
Persistent nausea and vomiting that does NOT resolve with positional changes is a red flag requiring further investigation for alternative or concurrent diagnoses. 2
Key warning signs include:
Constant nausea/vomiting unrelated to position changes suggests a vestibular or central nervous system disorder rather than typical BPPV. 2
Vomiting so severe that patients cannot tolerate diagnostic testing may indicate more complex vestibular pathology, though this can still occur with BPPV. 5
The presence of neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor loss) alongside persistent vomiting suggests central causes like stroke. 2
Management Approach
Short-Term Symptom Control
Vestibular suppressant medications and antiemetics are NOT routinely recommended for BPPV treatment, except for short-term management of severe autonomic symptoms like nausea or vomiting in severely symptomatic patients. 1
Antiemetics may be considered for prophylaxis in patients who have previously manifested severe nausea/vomiting with Dix-Hallpike maneuvers when a CRP is planned. 1
Examples of appropriate short-term use include patients who are severely symptomatic yet refuse therapy, or those who become severely symptomatic after a CRP. 1
Definitive Treatment
The most effective management is performing the canalith repositioning procedure (Epley maneuver), which addresses the underlying cause and resolves both vertigo and associated autonomic symptoms. 1, 6
A single CRP is more than 10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47). 1
Important Clinical Pitfalls
Do not dismiss BPPV as the diagnosis simply because vomiting is present—it is a recognized autonomic symptom. 3, 7
However, do not attribute persistent vomiting solely to BPPV if it continues beyond the brief vertigo episodes or occurs without positional triggers. 2
Vestibular suppressants have significant potential for harm (drowsiness, cognitive deficits, falls risk, especially in elderly patients) and should be avoided for routine BPPV treatment. 1
Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms, as persistent symptoms may indicate coexisting vestibular dysfunction or misdiagnosis. 1