Benign paroxysmal positional vertigo

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at May 18, 2016
StartDiseasesBenign paroxysmal positional vertigo

Vertigo is characterized by a spinning sensation triggered by a miscommunication in the body’s sensory systems. Benign paroxysmal positional vertigo, also known as BPPV, is one of the most common forms of the condition. Although BPPV can be uncomfortable and can increase the risk for falls, it is not life-threatening and rarely causes complications.


Definition & Facts

BPPV affects approximately 107 out of 100,000 people each year. It rarely affects children and is most common in adults over the age of 80. Other individuals at increased risk for developing BPPV include:

Anyone experiencing one episode of BPPV is likely to experience a repeat episode. In most cases, episodes of BPPV resolve within a couple of minutes, and individuals may be symptom-free between vertigo spells. As a general rule, treatment is only needed if the symptoms become so bad that they interfere with daily life, the symptoms are different than previous vertigo episodes, or if nausea and vomiting are severe enough to require medication.

Symptoms & Complaints

During an episode of BPPV, most people experience a sensation that that they or their surroundings are tilting, spinning, or whirling. This is different than dizziness, which is a woozy or unsteady feeling. With BPPV, the vertigo is often triggered by a change in head position.

The sensation is typically worse when tilting the head, turning over in bed, getting in and out of bed, or looking up or down. The vertigo may improve each time a person repeats the particular head movement and may disappear completely after three or four repeated motions.

In some instances, the spinning sensation may be severe enough to cause nausea and vomiting. BPPV will not cause constant dizziness that is unrelated to head movement or position change. It also will not cause fainting, headaches, coordination problems, paresthesia, or affect speech or hearing. Anyone experiencing these symptoms should seek immediate medical attention since they may be a sign of a serious condition, such as stroke or transient ischemic attack.


BPPV is an inner ear problem. It occurs when tiny calcium crystals, called otoconia, enter the semicircular canal of the inner ear. Normally, these calcium crystals are embedded in a gelatin-like material located on top of the utricle, which is one of the sensory organs of the inner ear.

When these crystals dislodge, they can float through the fluid-filled spaces and canals of the inner ear where they can come together in clumps. If they end up in the posterior semicircular canal, they can move as the head changes position, which causes a flow of fluid into the canal even after the head is still. This movement of fluid is what causes the spinning sensation of vertigo.

Nerve endings in the ear send messages to the brain that the body is moving, which does not correspond to what the other ear is sensing, what the muscles are doing, or what the eyes are seeing. Although certain factors can increase a person’s risk of BPPV, most cases are idiopathic, which means the actual cause is unclear.

Diagnosis & Tests

A doctor will perform a variety of physical tests to look for classic signs of BPPV, including:

  • Vertigo that is triggered by eye or head movements and resolves in less than one minute.
  • Dizziness when lying down and turning the head to the side while positioned slightly below the edge of the exam table.
  • Difficulty controlling eye movements.
  • Involuntary side-to-side eye movements, also known as nystagmus.

Additional testing may be ordered if the doctor is unable to determine the cause of the dizziness. An electronystagmography or videonystagmography may be used to check for abnormal eye movements suggesting an inner ear disease.

An MRI may also be used to rule out other conditions that could potentially cause vertigo. A hearing test may also be used to determine if the nerve connecting the inner ear and brain is working properly. Vertigo associated with hearing loss may indicate Meniere’s disease or labyrinthitis rather than BPPV.

Treatment & Therapy

BPPV that does not resolve on its own can usually be treated using a few simple positioning procedures performed at a doctor’s office. The goal of the positioning maneuvers is to move the calcium crystals from the inner ear canals to the vestibule where they won’t cause symptoms and can be reabsorbed. The technique involves guiding the patient through a series of movements with the head held in different positions and angles. Each position is held for approximately 30 seconds before transitioning to the next maneuver. In the beginning, the patient is likely to experience strong vertigo. The process is repeated until the vertigo and abnormal eye movements are no longer elicited.

In some cases, a small, hand-held vibrator may be positioned behind the ear to try to dislodge the stones. In very rare instances, surgery may be required if the semicircular canal becomes plugged to the point where the stone cannot move within the canal. Antiemetic medications may be prescribed for patients suffering from severe nausea and vomiting related to the vertigo. Treatment is effective in curing approximately 70 to 80 percent of BPPV cases. Roughly one-half of BPPV patients experience a recurrence over the long-term; however, these patients respond well to re-treatment.

Prevention & Prophylaxis

The majority of BPPV cases cannot be prevented. BPPV resulting from head injuries can be prevented by wearing appropriate safety equipment when biking, motorcycling, or playing contact sports. Individuals suffering from BPPV can take steps at home to lessen their symptoms, such as:

  • Use multiple pillows to elevate the head while sleeping.
  • Avoid sleeping on the side with the affected ear.
  • Get up slowly first thing in the morning, and sit on the side of the bed for a couple of minutes before standing.
  • Avoid leaning over to pick things up or tilting the head back to look up.
  • Avoid activities that require frequent turns or leaning over.