Benign paroxysmal positional vertigo

Daniel Selin
Apr 14
12 min read

Dizziness, nausea, feeling unsteady, neck pain, stiffness, decline in balance, motion sickness, episodic dizziness, semicircular canals of the inner ear, debris, vestibular system

Benign Paroxysmal Positional Vertigo (BPPV) is the most common disorder causing dizziness. BPPV leads to intense but short-lived episodes of vertigo triggered by movement or changes in head position. Although the precise mechanism behind BPPV is not fully understood, it's associated with the accumulation of debris in the semicircular canals of the inner ear. This results in a mismatch of signals that the brain has difficulty interpreting, leading to experiences of transient vertigo.

Dizziness episodes often last only a few seconds to about half a minute and they can be accompanied by nausea, which may persist much longer than the vertiginous spells. These episodes often resolve on their own within a few weeks, but in some cases, they may become chronic. BPPV is particularly common in women over the age of 40.

The treatment for BPPV involves repositioning maneuvers aimed at clearing the semicircular canals of accumulated debris using gravitational forces by moving the head and body.

A physician or physiotherapist experienced in treating BPPV can advise on the most suitable treatment for you while also ruling out other possible causes of dizziness.

Clinically Relevant Anatomy

Our balance system consists of three components: the vestibular system located in the inner ear, the proprioceptive system formed by muscles and joints, and the sum of visual sensory information. The central nervous system and the brain interpret the signals coming from these various systems, creating a cohesive understanding of body orientation and movement. If there is a mismatch in these signals, we may easily experience this as uncertainty or dizziness. In this article, we will focus on the structures of the inner ear, specifically highlighting the peripheral part of the vestibular system, which plays a crucial role in maintaining balance.

The structure and functions of the inner ear can be broadly divided into two parts:

The Cochlea: The cochlea is a spiral-shaped auditory organ that facilitates the detection of sound waves arriving from the outside and their transmission via the auditory nerves to the brain.
Peripheral Vestibular System: This component consists of three semicircular canals, the ampullae, and the otolithic organs (utriculus and saccule).

The primary function of the vestibular system is to assess the head's position and movement. It comprises both peripheral and central vestibular systems. The central vestibular system refers to the brain structures that receive and interpret information transmitted from the peripheral system while simultaneously considering the external sensory information regarding head and body orientation.

The peripheral vestibular system refers to the sensory organs located in the inner ear, which we will explore in more detail next.

BPPV arises from disturbances in the semicircular canals located in the inner ear. These canals and the fluid they contain, known as endolymph, are highly sensitive to gravity and changes in head position, meaning that any alteration in head movement can trigger an episode of dizziness.

We see the location of the inner ear — Location of the inner ear

The inner ear contains three semicircular canals (anterior, posterior and horizontal) that detect both linear acceleration and angular velocity. These canals are positioned at nearly right angles to each other, allowing for the detection of acceleration and the effects of gravity from any direction. The semicircular canals are filled with endolymph, which moves in response to gravitational forces.

At the base of each semicircular canal is an enlarged area called the ampulla, which contains a gelatinous substance known as the cupula. The cupula is attached to polarized hair cells and has the same density as the endolymph. The movement of the endolymph within the cupula generates either an excitatory or inhibitory response, depending on the direction of the semicircular canal and the movement.

Under normal circumstances, these signals are consistent and reinforce each other, allowing for easy interpretation by the brain. However, in cases of dysfunction, these signals can become contradictory, leading to difficulties in interpretation and resulting in feelings of uncertainty and dizziness.

A detailed picture of the inner ear — Inner ear structure

In addition to the semicircular canals, the inner ear contains calcium crystals (otoconia), which typically reside in the utriculus and saccule. These structures form the otolithic organs, which are responsible for sensing linear movement within the gravitational field. In individuals with BPPV, the calcium crystals can become dislodged from their usual position in the utriculus or saccule and may migrate into one of the semicircular canals over time.

When the head is moved, this leads to a disturbed movement of the cupula and endolymph due to the accumulation of calcium crystals. This disrupted fluid movement sends signals to the brain indicating that rotational movement is occurring. Simultaneously, the brain receives a different signal from the healthy ear. This mismatch in signals from the right and left vestibular systems leads to feelings of dizziness. The sensation of dizziness often only lasts a moment, as the endolymph and calcium crystals quickly return to a resting state once the movement stops.

In rare cases, the crystals may adhere to the cupula of a semicircular canal, making it heavier than the surrounding endolymph. When the head is reoriented relative to gravity, the cupula is pushed down by the dense particles, causing an immediate and sustained signal of movement to be sent to the brain. In this situation, dizziness will not resolve until the head is moved out of the provocative position, as even when the endolymph returns to a resting state, the adhered calcium crystals continue to displace the hair cells, sending a signal to the brain indicating ongoing movement.

Etiology and Epidemiology

BPPV is predominantly idiopathic, meaning that its exact cause is often unknown or it arises spontaneously. As people age, the vestibular system in the inner ear may undergo degeneration, increasing the prevalence of BPPV. Head trauma can also trigger inner ear-related dizziness. Infections affecting the inner ear or complications from surgery may further contribute to the occurrence of the condition.

BPPV is observed nearly three times more frequently in women than in men, possibly due to hormonal factors. Other risk factors include:

High blood pressure
High cholesterol
Menopause
Allergies
Migraine
Chronic Obstructive Pulmonary Disease (COPD)
Meniere's disease
Infections

Approximately one in three individuals will experience dizziness at least once in their lifetime, with over a quarter of these cases being attributed to BPPV. The condition is typically seen in individuals over the age of 40, although it can also occur in younger individuals. About 90% of BPPV cases are due to disturbances in the posterior semicircular canal. Symptoms often last from a few weeks to a few months, with a recurrence rate of about one in three. However, if left untreated, dizziness can become chronic, making early intervention and appropriate treatment crucial.

BPPV can be triggered by any activity that stimulates the semicircular canals, including:

Tilting and rotating the head
Turning over in bed
Looking up or down
Rapid head movements
Traveling in a car or other vehicle

Additionally, lack of sleep, stress, anxiety or changes in atmospheric pressure can exacerbate symptoms. Patients with previous vestibular issues or balance disorders may also have an increased risk of developing BPPV.

Symptoms

BPPV causes brief episodes of rotational dizziness that last less than a minute and are triggered by head movements. Symptoms can vary among individuals, with the following being the most typical:

Feeling of spinning or movement: The patient experiences a sensation that they are spinning or moving, even when they are stationary.
Perceived spinning of the world: The surrounding environment appears to be spinning or moving around the patient.
Loss of balance: Dizziness can impair balance, potentially increasing the risk of falls.
Nausea and vomiting: Symptoms may lead to feelings of nausea and in severe cases, even vomiting.
Hearing loss: While hearing impairment is usually indicative of another issue, it is not entirely excluded that BPPV could result in dizziness along with some hearing reduction.
Visual disturbances: Blurred vision or sensations that objects are jumping or moving, even when they are stationary, can occur. This is associated with the nystagmus caused by BPPV, where the eyes make rapid, involuntary back-and-forth movements.

The symptoms of BPPV are often experienced as highly unpleasant and anxiety-inducing. Many interpret these symptoms as a sign of a serious illness, which can increase anxiety and affect daily functioning. Because of this, it is essential to seek medical attention as soon as possible. Early intervention improves treatment outcomes and helps prevent unnecessary suffering from symptoms. Understanding the nature and background of the symptoms can also reduce anxiety, making the symptoms feel less intimidating.

Differential Diagnosis

Differentiating BPPV from other causes of dizziness is crucial for accurate diagnosis and effective treatment. Healthcare professionals carefully assess the patient's symptoms and background to ensure that the correct diagnosis can be made and that potential serious issues or diseases are ruled out. Below is a brief overview of common disorders and conditions that can cause dizziness:

Otological Causes

Meniere's Disease: This condition is associated with fluid accumulation in the inner ear, leading to episodic dizziness, hearing loss, tinnitus (ringing in the ears) and a feeling of pressure in the ear. The dizziness caused by Meniere's disease lasts significantly longer than the dizziness episodes associated with BPPV.
Vestibular Neuritis: This condition refers to inflammation of the vestibular nerve, which often leads to sudden and severe dizziness, sometimes accompanied by nausea. Dizziness caused by vestibular neuritis can last for several days but typically does not involve hearing loss.
Labyrinthitis: This is a viral or bacterial infection of the inner ear, causing not only dizziness but also tinnitus and hearing loss, which can become chronic if left untreated.
Post-Traumatic Dizziness: An impact or injury to the head can cause dizziness that may start immediately or develop later, often accompanied by nausea.

Neurological Disorders

Migraine-Associated Dizziness: Symptoms can occur during a migraine attack, before it or after it.
Vertebrobasilar Insufficiency (VBI): Caused by weakened blood flow in the back of the brain, this condition can lead to dizziness as well as visual disturbances, speech difficulties, swallowing problems and other neurological symptoms.
Multiple Sclerosis (MS) and Other Demyelinating Diseases: These conditions can affect the vestibular system, resulting in dizziness and feelings of instability.

Other Possible Causes

Anxiety or Panic Disorders: Psychological conditions can cause dizziness that may mimic vestibular dizziness. Stress and anxiety can also exacerbate existing dizziness symptoms.
Cervicogenic Dizziness: This type of dizziness arises from sensory mismatch in the afferent information from the neck, where proprioceptive input from the cervical spine structures conflicts with the information conveyed by the vestibular system. Cervicogenic dizziness is often accompanied by neck stiffness or pain and headaches.
Medication Side Effects: Certain medications, such as antihypertensives or those affecting the central nervous system, can cause dizziness or a sense of instability as a side effect.
Blood Pressure-Related Dizziness: This can occur due to either standing up too quickly (low blood pressure) or excessive physical exertion (high blood pressure). Such dizziness often resolves quickly once blood pressure stabilizes.

Diagnosing BPPV

The diagnosis of BPPV begins with a thorough interview at the clinic, during which the patient's subjective symptoms are described and discussed. Accurate patient anamnesis is crucial not only for establishing the correct diagnosis but also for ruling out serious illnesses.

During the interview, it is important to clarify the nature of the symptoms, their duration, intensity and any possible precipitating or alleviating factors. It is also beneficial to assess the patient's underlying health conditions, family history and any previous injuries. If the anamnesis and interview suggest BPPV and there is no indication of serious illness, the clinician can proceed to clinical tests.

The goal of the clinical tests is to provoke dizziness or induce nystagmus, at which point the test is interpreted as positive for BPPV. The tests include a variety of movement sequences depending on which semicircular canal is being examined. Each semicircular canal and ear has its own specific tests and maneuvers.

Most cases of BPPV are due to problems with the posterior semicircular canal, leading us to rely on the Dix-Hallpike test. This is one of the most common and reliable tests for diagnosing BPPV.

The Dix-Hallpike Test

The Dix-Hallpike test is named after its developers, neurologist Margaret Dix and surgeon Charles Hallpike, and has been in use since 1952. It remains the most reliable and widely used method for diagnosing BPPV. The Dix-Hallpike test consists of a short sequence of movements designed to provoke dizziness and possible nystagmus.

Here’s a step-by-step guide that can also be attempted at home:

An infogram of how to perform the dix-hallpike maneuver — The Dix-Hallpike test

Sit on the examination table (or bed) with your legs extended.
Turn your head 45 degrees toward the affected ear.
The examiner supports your head while you quickly lie back, keeping your head tilted and bent slightly backward (about 30 degrees). The goal is to position the affected ear toward the floor. At home, this can also be performed by letting your head hang over the edge of the bed or by placing a pillow under your upper back so that your head can hang over it.
Keep your eyes open and remain in this position for 1-2 minutes.
The test is positive if this causes a clear sensation of dizziness and especially if associated with nystagmus.
The test is performed on both ears.

If the Dix-Hallpike test is negative, but the symptoms and information from the interview strongly suggest BPPV, then both the anterior and horizontal semicircular canals can be tested next. However, these conditions are less common than issues with the posterior semicircular canal, so it is recommended to start with the posterior canal test.

Rahko Test

The Rahko test, developed by Tapani Rahko, is used to diagnose BPPV resulting from issues with the anterior semicircular canal. This test is performed while standing:

The patient bends about 60 degrees forward from the hips, closes their eyes and quickly straightens up while keeping their eyes closed.
The patient remains standing with their eyes closed for one minute.
A positive test result causes lateral movement toward the side with symptoms and the patient may need to take support steps to prevent falling.
It is advisable to repeat the test a few times, as lateral movement may increase with repetition, contributing to a more reliable result.

WRW Test

Another test developed by Tapani Rahko is called the WRW test or the Walk-Rotate-Walk test, which assesses the horizontal semicircular canal. The test itself is very simple but requires significantly more from the patient compared to supine tests.

The patient walks three steps forward and then rotates 180 degrees on one foot.
After that, the patient walks another three steps and rotates 180 degrees on the other foot.
The walking and rotations are performed a minimum of three times on each side.
The test result is positive if the patient needs to take support steps to maintain balance after turning, or if there is significant swaying during the test.

Treatment

The treatment of BPPV is based on positional and movement therapies, known as maneuvers, aimed at removing debris from the semicircular canals of the inner ear. While untreated BPPV may resolve on its own, there is a higher risk of the condition becoming chronic, making timely intervention advisable.

Research indicates that the movement therapies used, such as the Epley, Rahko and Lempert maneuvers, are safe and effective. The chosen maneuver depends on which of the three semicircular canals is causing the symptoms. Treatments can be performed in clinic settings by a therapist or physician or as self-treatment at home.

Epley Maneuver: An effective treatment for BPPV originating from the posterior semicircular canal.
Rahko Maneuver: Used for treating BPPV stemming from the anterior semicircular canal.
Lempert Maneuver: An effective method for addressing BPPV caused by the horizontal semicircular canal.

Epley Maneuver (Posterior Semicircular Canal)

The Epley maneuver is an effective treatment method for BPPV originating from the posterior semicircular canal. This treatment can be performed on an examination table or bed and can also be executed as self-treatment. It is recommended to repeat the maneuver 3-4 times a day and to continue until symptoms no longer occur.

Epley maneuver for right ear — The Epley maneuver (Right ear)

Sit on the edge of the bed and turn your head approximately 45 degrees toward the affected ear.
Quickly lie back, keeping your head tilted and slightly backward bent (about 30 degrees). A pillow should support your shoulders, allowing your head to tilt back. Remain in this position for at least 30 seconds or until any symptoms subside.
Rotate your head 90 degrees to the other side without lifting it. Stay in this position for at least 30 seconds or until any symptoms subside.
Rotate your head and body another 90 degrees forward so that you are now looking down. Remain in this position for at least 30 seconds or until any symptoms subside.
Finally, rise to a sitting position while keeping your head turned in the same direction. Sit quietly for at least 30 seconds or until any symptoms dissipate.

Rahko Maneuver (Anterior Semicircular Canal)

The Rahko maneuver is used to treat BPPV arising from the anterior semicircular canal. This treatment is performed while lying on the side on an examination table or bed and it can also be conducted as self-treatment. It is recommended to repeat the maneuver 3–4 times a day and to continue until symptoms resolve.

Lie on your side with the unaffected ear facing up.
Let your head drop 45 degrees towards the floor by allowing it to hang over the edge of the bed. Stay in this position for at least 30 seconds or until symptoms improve.
Raise your head back to a horizontal position and remain there for at least 30 seconds or until symptoms ease.
Next, tilt your head 45 degrees in the opposite direction (towards the ceiling). You may place your hand under your head for support. Stay in this position for at least 30 seconds or until symptoms improve.
After completing the maneuver, sit in a sturdy chair for 3 minutes to allow time for stabilization.

Lempert Maneuver (Horizontal Semicircular Canal)

The Lempert maneuver is utilized for treating BPPV caused by the horizontal semicircular canal. This treatment is performed while lying down and it includes a series of four distinct positions. Each position is held for at least 30 seconds or until the dizziness symptoms resolve. It is advisable to repeat the maneuver 3–4 times a day and to continue until symptoms no longer appear.

Begin lying on your back, either on an examination table or at home on a bed.
Roll onto your side with the unaffected ear facing upward and remain in this position until symptoms improve.
Roll to a prone position with your forehead resting on the examination table or bed. Stay in this position until symptoms ease.
Finally, roll onto your side with the affected ear facing upward and hold this position until symptoms resolve.
After completing the maneuver, sit in a sturdy, arm-supported chair for 3 minutes.

Conclusion

BPPV is a common and highly treatable cause of dizziness that can significantly impact a patient's quality of life. Early diagnosis and effective treatment are crucial in managing symptoms and improving overall well-being.

Positional therapies, such as the Epley, Rahko, and Lempert maneuvers, provide patients with the opportunity to rapidly and effectively alleviate dizziness.

It is important to remember that although the symptoms of BPPV can initially seem daunting, the underlying causes are well understood and the treatment is both effective and safe. The causes of dizziness should always be thoroughly investigated to facilitate appropriate treatment and to rule out more serious conditions.

Timely and effective treatment not only reduces symptoms but also alleviates anxiety, ultimately enhancing overall well-being.

Therapeutic Physiology