Benign Paroxysmal Positional Vertigo (BPPV)

BPPV stands for:

• Benign as although it can be quite disabling, it is not due to serious disease
• Paroxysmal because it occurs in short bursts of up to one minute
• Positional as it is provoked specifically by movement to or from certain positions
• Vertigo – dizziness defined as an illusion of movement.

The vertigo of BPPV is generally rotational (like getting off a roundabout) but sometimes sufferers, on lying down, will feel that they are falling through the bottom of the bed or, on getting up, that they are being thrown back onto it.

The classic provoking movements to induce BPPV are lying flat, sitting up from lying flat, turning over in bed, looking up (e.g., hanging washing) or bending down, especially if also looking to the side.

The duration of the vertigo is brief; usually 5-30 seconds but very occasionally lasts up to two minutes.

With each episode of vertigo, you may feel sick, but people rarely vomit. The nausea may last an hour or so even though the vertigo lasts just seconds.

Between episodes of BPPV you feel well. Many people who develop BPPV realise which head movements trigger their symptoms and so instinctively avoid doing those movements.

BPPV often has no known cause. Most people affected are over 40 years and some cases of BPPV may follow a head injury or an inner ear infection.

BPPV is triggered when loose chalk crystals (“otoliths” or “otoconia”) get into the wrong part of the inner ear. These microscopic crystals should normally be embedded in a lump of jelly within the inner ear. The crystals weigh the jelly down and make that part of the ear sensitive to gravity. The crystals are constantly being re-absorbed and re-formed and over time fragments come loose. Lying flat can then occasionally cause some of the loose debris to fall into one of the semi-circular canals, the parts of the ear responsible for sensing rotation. Movement in the plane of the affected canal causes the crystals to move along the canal, stimulating it and giving the sensation of rotation.

Other possible common causes of vertigo besides BPPV include vestibular neuritis or labyrinthitis and Ménière’s disease.

You should consult with your GP if you experience symptoms of dizziness or vertigo that are severe or persistent or keep coming back.

You should contact your GP or the emergency services as a matter of urgency if you experience sudden onset dizziness accompanied by any of the following:

• a new, different or severe headache
• after a head injury
• falling or trouble walking
• fainting or collapsing
• chest pain
• hearing loss or a ringing noise (tinnitus)
• changes to your behaviour
• numbness in your face or slurred speech
• double vision or visual loss

The symptoms of BPPV are quite characteristic and the diagnosis may be made just from the history and by the exclusion of other disorders that can cause similar dizzy symptoms.

When attacks are occurring, the Dix-Hallpike positional test is diagnostic. BPPV causes specific jerking movements of the eyes (nystagmus) during the Hallpike test which can help to confirm a diagnosis.

This test should always be performed by a clinician such as a doctor or a physiotherapist and involves sitting on a couch and being asked to lie back and move your head in certain directions. These set movements in people with BPPV will usually trigger an episode of vertigo.

BPPV is a condition that usually goes away on its own after several weeks or months without any treatment. One study reported that the condition had resolved in many people with BPPV in an average of 10 weeks. The otoliths that precipitate the symptoms are thought either to dissolve or move to a place in the inner ear where they cause no symptoms.

As BPPV is basically a mechanical disorder, drugs have no effect and should be avoided.

If symptoms are particularly troublesome or do not appear to be resolving, there are several treatments that may be helpful.

These so-called “particle repositioning manoeuvres” take you through a sequence of controlled movements of the head that make the troublesome otoliths (crystals) float out of the wrong inner ear compartments where they are causing the unwanted symptoms. They are usually performed by a specialist rather than your GP who might not be familiar with them.

After successful treatment with these procedures, it is quite common to have some dizziness for up to three months afterwards.

The Epley manoeuvre

The most common particle repositioning manoeuvre is called the Epley manoeuvre. This often works if you have fragments of debris at the bottom of your posterior semi-circular canal (the most common scenario).

This is done by a series of four movements of the head. After each movement, the head is held in the same place for 30 seconds or so.

The movements of the head basically cause the semi-circular canals to rotate around in such a way that gravity moves the otolith fragments out from the posterior canal and into a part of the inner ear where they then settle and cause no symptoms.

Some studies report that the Epley manoeuvre is successful in stopping symptoms in about 8 in 10 cases with just one treatment. If the first treatment does not work, there is still a good chance that it will work in a repeated treatment session a week or so later.

The Epley manoeuvre may be performed by your GP, a physiotherapist or a specialist audiologist (through GP referral to your local ENT department).

There is also a modified or “home” Epley manoeuvre that you can perform yourself, but this needs to take in to account on which side the inner ear is affected and should not be attempted by people with certain underlying conditions such as some types of neck, back or blood circulation problems, those who have had a recent stroke or who are pregnant.

It is therefore important that you consult with a healthcare professional such as your GP or ENT specialist before attempting this type of exercise.

Brandt-Daroff exercises

You may be recommended to do these if the Epley manoeuvre does not work. These exercises involve a different way of moving the head compared to the Epley manoeuvre and are easier to perform unsupervised.

No treatment

If the Epley manoeuvre or Brandt-Daroff exercises are not successful, or not done, you can remain optimistic that the condition will eventually resolve by itself.

Surgery

Treating BPPV with surgery is extremely rare, in most cases the condition either improves by itself or can be cured by the Epley manoeuvre. If symptoms persist and cannot be eased, your GP may consider a referral to an ENT specialist.

There are things that you can do to ease vertigo symptoms when they’re happening, and to reduce the number of episodes you have.

• lie still in a quiet, dark room to reduce the spinning feeling
• move your head carefully and slowly during daily activities
• sit down straight away when you feel dizzy
• turn on the lights if you get up at night
• use a walking stick if you’re at risk of falling
• sleep with your head slightly raised on 2 or more pillows
• get out of bed slowly and sit on the edge of the bed for a while before standing up
• try to relax – anxiety can make vertigo worse
• avoid bending over, squat to lower yourself instead
• do not stretch your neck – for example, whilst reaching up to a high shelf

The DVLA recommends that you should stop driving if you have sudden, unexpected and disabling attacks of dizziness. Visit the GOV.UK website for more information on Dizziness or vertigo and driving.

You should inform your employer if BPPV could pose a risk to yourself or others in your job. For example, if you use ladders, operate heavy machinery, or drive.

To avoid falls around the home, get out of bed slowly and avoid jobs around the house that involve looking upwards.

Useful information about BPPV

• Benign paroxysmal positional vertigo (BPPV) Brandt-Daroff exercises – University Hospitals Dorset NHS Foundation Trust
• Dix-Hallpike and Epley manoeuvres for BPPV – Royal Berkshire NHS Foundation Trust
• Brandt-Daroff Exercises for BPPV – University Hospitals Sussex NHS Foundation Trust
• Dizziness & Balance problems – Brain & Spine Foundation

Videos about BPPV

Labyrinthitis and Vertigo (BPPV): Hazel’s story | NHS

Published: 6 Nov 2017

Vertigo – Dix-Hallpike Manoeuvre from BMJ Learning | BMJ Learning

Published: 6 Feb 2014

Vertigo – Epley manoeuvre from BMJ Learning | BMJ Learning

Published: 6 Feb 2014

NHSGGC – Vestibular Exercises 001 Epley R | NHS Greater Glasgow and Clyde

Published: 7 Jul 2020

NHSGGC – Vestibular Exercises 002 Epley L | NHS Greater Glasgow and Clyde

Published: 7 Jul 2020

NHSGGC – Vestibular Exercises 007 Brandt Daroff | NHS Greater Glasgow and Clyde

Published: 7 Jul 2020

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