Benign Paroxysmal Positional Vertigo (BPPV): Cause and Treatment
Primary Mechanism
BPPV is caused by dislodged calcium carbonate crystals (otoconia) that break free from the utricle and migrate into the semicircular canals of the inner ear, creating abnormal stimulation when the head changes position relative to gravity. 1
The fundamental pathophysiology involves two distinct mechanisms 1:
- Canalithiasis: Free-floating otoconia move within the semicircular canal
- Cupulolithiasis: Otoconia adhere directly to the cupula
Canal Distribution
Risk Factors and Associated Conditions
Most BPPV cases occur spontaneously without identifiable cause, but specific associations include 2:
- Age over 50 years (most significant risk factor) 1
- Head trauma
- Prolonged bed rest or preferred sleep side positioning
- Inner ear disorders (vestibular neuritis, Menière's disease)
- Diabetes
- Osteoporosis
- Migraine
- Post-surgical procedures
Clinical Presentation
Typical Symptoms
Patients experience brief episodes of intense spinning vertigo lasting seconds to one minute, triggered by specific head position changes 2, 3:
- Rolling over in bed
- Looking up
- Bending over
- Sitting up from lying down
Associated features include 2:
- Nausea (sometimes vomiting)
- Severe disorientation
- Transient instability after episodes resolve
Atypical Presentation in Older Adults
In seniors, BPPV may present as isolated instability with position changes rather than classic spinning vertigo 2, making diagnosis more challenging but critically important given the 12-fold increased fall risk 1.
What BPPV Does NOT Cause
BPPV does not produce 2:
- Constant severe dizziness unaffected by position
- Hearing loss
- Syncope or fainting
- Neurological symptoms (weakness, speech changes, diplopia)
Diagnosis
Bedside Testing
The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior canal BPPV, while the supine roll test diagnoses horizontal canal BPPV 2, 1.
Positive Dix-Hallpike Findings (Posterior Canal BPPV)
- Torsional and upbeating nystagmus 4
- 5-20 second latency before onset 4
- Crescendo-decrescendo pattern 4
- Fatigues with repeated testing 4
- Resolves within 60 seconds 4
Imaging and Laboratory Testing
Medical imaging (CT, MRI) and laboratory tests cannot confirm BPPV and are not indicated in typical presentations 2. Neuroimaging is only warranted when red flags suggest central pathology 1.
Critical Red Flags Requiring Neuroimaging
Immediate neuroimaging is mandatory if any of the following are present 1, 4:
- Downbeating nystagmus without torsional component on Dix-Hallpike
- Direction-changing nystagmus without head position changes
- Constant severe dizziness unaffected by position
- Associated hearing loss
- Syncope or fainting
- Failure to respond to canalith repositioning procedures
- Any neurological signs (dysarthria, limb weakness, ataxia, diplopia)
- New-onset severe headache with vertigo
- Severe postural instability with falling
Treatment
First-Line Treatment: Canalith Repositioning Procedures
Bedside canalith repositioning maneuvers (CRPs) are the primary treatment for BPPV, with approximately 80% success rates after 1-3 treatments 2. These maneuvers guide the displaced crystals back to their original location in the utricle.
Specific Maneuvers by Canal
Treatment Protocol
Perform the canalith repositioning procedure immediately upon positive diagnostic testing 4. The same session can include both diagnosis and treatment 5.
Repeated testing and treatment within the same session is safe and effective, with low risk of canal conversion 5. In 91% of posterior canal cases, effective treatment occurs within 2 maneuvers or less 5.
Expected Treatment Response
- Some patients experience immediate symptom resolution 2
- Others report motion sickness-type symptoms and mild instability for hours to days post-treatment 2
- Brief distress from vertigo and nausea during the actual maneuver is common 2
Post-Treatment Considerations
Nineteen percent of patients experience post-treatment downbeating nystagmus and vertigo ("otolithic crisis") after the first or second consecutive Epley maneuver 5. Clinicians must remain vigilant for this complication to prevent injurious falls 5.
What NOT to Prescribe
Vestibular suppressants (meclizine, dimenhydrinate) should NOT be prescribed for BPPV as they prevent central compensation 4. Medications may only be used for immediate relief of severe nausea 2.
Indications for Specialist Referral
Refer to a specialist (otolaryngologist, audiologist, or vestibular physical therapist) when 2:
- Severe disabling symptoms
- Older adults with history of falls or fear of falling
- Difficulty moving (joint stiffness, weakness)
- Treatment failure after appropriate maneuvers
- Atypical presentations or equivocal findings
Natural History and Recurrence
BPPV can resolve spontaneously within weeks if left untreated 2, but this approach is not recommended due to increased fall risk during the symptomatic period, particularly in older adults 2, 1.
The disease has a significant recurrence rate, making patient education about symptom recognition essential 2. Recurrence is more common in patients with 2:
- BPPV secondary to head trauma
- BPPV secondary to vestibular neuritis
- Coexisting Menière's disease
- Migraine-associated vertigo
Special Considerations for Older Adults
Older patients with BPPV require heightened clinical attention due to 12-fold increased fall risk when symptomatic, greater susceptibility to serious injury, and atypical presentations 1.
Assess older patients for modifying factors 1:
- Impaired mobility
- CNS disorders
- Lack of home support
- Increased baseline fall risk
Seniors should seek professional help quickly to resolve symptoms and minimize fall risk 2.
Treatment Failure: Reassessment Strategy
When symptoms persist after appropriate treatment, consider 2:
- Multiple canal involvement: The second canal's involvement may become evident only after treating the first
- Incorrect canal identification: Initial treatment may have targeted the wrong canal
- CNS disorders masquerading as BPPV: Found in 3% of treatment failures 2
- Coexisting vestibular dysfunction: Particularly in patients with history of head trauma, vestibular neuritis, Menière's disease, or migraine 2
Patient Education Priorities
Educate all patients about 2:
- Fall risk: BPPV significantly increases fall risk, especially in older adults
- Recurrence potential: BPPV can return and requires repeat treatment
- Safety precautions: Avoid situations where sudden vertigo could cause injury (climbing ladders, driving during symptomatic periods)
- When to seek care: Return if symptoms recur or if new neurological symptoms develop