Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is a common disorder of the inner ear. It is also known as postural vertigo or positional vertigo.

Benign paroxysmal positional vertigo is characterised by intense but brief periods of vertigo that happen when moving the head, such as when rising from the bed in the morning. It appears as dizziness, nausea and unsteadiness. It is estimated to affect 2.4% of the general population and accounts for 20-30% of the cases of dizziness in older adults.

Benign paroxysmal positional vertigo:

• Is not serious;
• Brings about a swift onset of vertigo, and;
• Is characterised by dizziness that occurs when the person is in specific positions (positional vertigo).

Although this disorder is not serious, it can still be very disruptive to both work and social life, and may be associated with an increased risk of falling.

Benign paroxysmal positional vertigo tends to affect only one ear. It is thought to occur when small particles (crystals) inside the inner ear migrate to a different area of the inner ear, causing overstimulation of nerves. These nerve messages send incorrect information to the brain that the head is spinning, even though the head has only moved slightly.

Causes

Most cases of benign paroxysmal positional vertigo have no known cause; however, some established causes can include:

• Degenerative changes associated with the normal ageing process;
• Head injury;
• Viral infection;
• Nerve inflammation;
• Side effects from certain medications, and;
• Complications of ear surgery.

Signs and symptoms

The symptoms experienced by someone with benign paroxysmal positional vertigo may vary, but may include:

• Dizziness with certain head positions;
• A loss of balance;
• Blurred vision;
• Vomiting;
• Nausea, and;
• Involuntary eye movements.

Symptoms may be intermittent, and stop for several weeks or months and then come back again. Each episode may be intense, but may only last for around 30-60 seconds.

Methods for diagnosis

Medical history and physical examination

Your doctor will diagnose benign paroxysmal positional vertigo based on the findings from a medical history, physical examination and balance tests. The medical history and physical examination will help to rule out other causes of vertigo.

Dix-Hallpike test

The Dix-Hallpike test is performed as part of the diagnosis, and involves tilting your head backwards while you lie on an examination table and move your head to different positions. During this procedure, the doctor will observe the eye movements that accompany your changing positions.

Balance tests

Balance tests are performed to ensure that the vertigo is not being caused by problems in the brain.

Other tests

A diagnosis can typically be made based on the outcome of your medical history and physical examination. However, some cases may require further testing, such as electronystagmography. This test uses electrodes placed on the face to accurately measure head and eye movements.

Rarely, magnetic resonance imaging (MRI) may be used to rule out acoustic neuroma, which is a non-cancerous brain tumour of the nerve that carries information from the inner ear to the brain. Acoustic neuroma can result in similar symptoms to benign paroxysmal positional vertigo.

Types of treatment

Treatment aims to move the migrated particles (crystals) in the inner ear back to their correct position.

Epley manoeuvre

The Epley manoeuvre is commonly used to reposition the crystals. This procedure is carried out by a healthcare practitioner and involves a series of four movements of the head. First while sitting up, the person's head is turned about 45° to the side that normally causes the vertigo. They are then laid down quickly backwards with their head hanging slightly over the edge of the examination table. The head is kept there for around 30 seconds, then turned 90° to the opposite side. After 30 seconds, both the head and body are turned and effectively rolled over, with the head pointing down towards the ground at an angle of 45°. This position is held for 30 seconds, and then the person is brought upright.

After the procedure has been carried out, the person will need to avoid lying flat or placing their treated ear below shoulder level. They will also be advised to sleep with their head elevated on extra pillows, to ensure the particles settle and are resorbed.

The Epley manoeuvre aims to move the particles in the inner ear back to their correct position.  

Although the Epley manoeuvre is highly effective, some people may require further treatment. After being trained by a healthcare practitioner, a person can perform a series of positional manoeuvres at home, similar to the Epley manoeuvre. This is repeated 2-3 times a day, for up to three weeks.

Some cases may also require medication; motion sickness medication may be prescribed for short-term use.

Potential complications

Although benign paroxysmal positional vertigo rarely causes any complications, in some cases, frequent vomiting may lead to dehydration and there is also an increased risk of falls because of the lack of balance and dizziness.

Prognosis

Most cases either resolve on their own, or are cured with the Epley manoeuvre. In about half of people, the disorder may recur either months or years later.

Prevention

Most cases of benign paroxysmal positional vertigo cannot be prevented, but cases associated with head injury may be prevented by wearing head protection during sporting activities.