Benign Positional Paroxysmal Vertigo (BPPV)

Walking and making a turn very quickly and feeling dizzy? Abruptly turning your head, changing directions or even watching things move past; have any of these elicited dizziness or a general feeling of imbalance? All these movements fall under the umbrella category of dizziness and are a symptom called vertigo: type of dizziness associated with continual movement feedback after the cessation of a certain movement. The sensation includes swaying, tilting and spinning no different to spinning on a swivel chair repeatedly then stopping.


There are 2 forms of vertigo: peripheral and central. Central causes may include migraines, multiple sclerosis, strokes, vertebrobasilar insufficiency and neoplasms. In this article, we will cover the most common perispheral vertigo cause: Benign Positional Paroxysmal Vertigo (BPPV) (amongst other causes such as meniere’s disease and labyrinthitis). Benign paroxysmal positional vertigo is the most common cause, accounting for over one-half of all cases.

What is it

Within our ear there are 3 free flowing canals called out semicircular canals. These 3 rings help us orientate our head in space like a gyroscope. Amongst these canals lie fixed calcium-carbonate crystals which amongst with hair cells relay positional changes of the head including tilting, turning, and linear acceleration.

In  BPPV, these crystals dislodge and remain free flowing within the semicircular canals (canalithiasis). These crystals then become a problem when we turn our head in space. The crystals persist to flow and send us information that we are moving even when the movement has stopped. The incongruency between your two ears (vestibular systems) leads to a sense of vertigo. While one side has stopped sending feedback, the other side continues inappropriately causing symptoms of dizziness, spinning, and/or swaying. BPPV however will not elicit symptoms when we are still, therefore rest is most ideal after a symptomatic episode.

Movements that may trigger BPPV symptoms include:

• Tilting the head

• Rolling over in bed

• Looking up or under

• Sudden head motion

BPPV Symtoms include:

• Vertigo

• Nausea

• Visual disturbances (nystagmus)

• Vomiting

• Loss of balance

• Syncope (fainting)

Risk factors include:

• Female sex

• Hypertension (HTN)

• Hyperlipidemia

• Cerebrovascular disease

• Menopause

• Allergies

• Migraine

• Chronic Obstructive Pulmonary Disease (COPD)

• Surgical procedure such as a cochlear implant

• Infection


If a true BPPV presentation is diagonised using the Dix-Hallpike maneuver to localize the problematic vestibular system, another movement called the Epley maneuver can be performed. The maneuver seeks to relocate the canalithiasis/free flowing debris using gravity. Following this movement, patients are required to avoid turning in the symptomatic direction and required to stay upright or up to 45degrees. Patients will also need to sleep in a recumbent bed position to avoid disruption of the crystals. If symptom relief is transient, it is encouraged that the test and treatment is performed again, as there is symptomatic relief. Therapists may need to complete this maneuver 1 to 3 visits for complete resolution of symptoms.  Please note that the Dix-Hallpike and Epley are not always tolerated by patients with BPPV, in which case treatment is symptomatic. Alternatively, if your vertigo is of systemic origin or an infection origin, antihistamines, such as Antivert (meclizine), Benadryl (diphenhydramine), or Dramamine (dimenhydrinate) to help vertigo episodes.

With the variable complaints that come with different presentations of vertigo/dizziness. Clinicians may assess and treat for BPPV, benefiting the patient as they may then get back to their activities of daily living.

Article written by Physiotherapist Joshua Shum

Posted in Uncategorized.