Overview
Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder characterized by short, severe episodes of dizziness triggered by changes in head position. It is the most common cause of vertigo; its frequency increases with age.
It is caused by calcium crystals (otoconia) becoming dislodged into the balance canals of the inner ear. It is usually not serious and can be treated with simple maneuvers.
Symptoms
- Severe dizziness (sensation that surroundings are spinning)
- Usually lasts 30 seconds to 1 minute
- Triggered by certain head positions:
- Getting out of bed
- Lying down on bed
- Rolling over in bed
- Looking up
- Bending over
- Nausea, vomiting
- Loss of balance
- Abnormal eye movements (nystagmus)
Hearing loss, tinnitus, and headache do not occur in BPPV. If these symptoms are present, another condition should be considered.
Causes
Calcium carbonate crystals in the inner ear structure called the utricle become dislodged and migrate to the semicircular canals. When the head moves, these crystals move and send incorrect balance signals.
Risk factors:
- Being over 50 (most common 50-70)
- Female sex
- Previous head trauma
- Other inner ear diseases
- Previous vestibular neuritis
- Meniere's disease
- Prolonged bed rest
- Vitamin D deficiency
- Migraine
- Diabetes, hypertension
- Osteoporosis
Complications
- Falls and injuries (especially in the elderly)
- Accidents (attacks while driving)
- Anxiety, avoidance behaviors
- Decreased quality of life
- Chronicity (if not properly treated)
When to See a Doctor
Scheduled visit:
- New-onset dizziness
- Recurring dizziness attacks
- Dizziness triggered by specific positions
Emergency:
- Dizziness with severe headache
- Double vision
- Speech disturbance
- Facial or arm weakness (stroke signs)
- Fever
- Sudden hearing loss
- Weakness in arms or legs
- Change in consciousness
- Severe nausea, vomiting (bedridden)
Diagnosis and Treatment
Diagnosis:
- Detailed history
- Dix-Hallpike maneuver (diagnostic test)
- To exclude other causes of vertigo:
- Hearing test
- Vestibular tests (videonystagmography)
- Brain MRI (when needed)
- Blood tests
Treatment:
1. Repositioning maneuvers (most effective):
- Epley maneuver: Returns crystals to their original position
- Performed by a doctor
- 80-90% success rate
- Semont maneuver
- Brandt-Daroff exercises (can be applied at home)
After the maneuver, in the first 24-48 hours:
- Do not move your head
- Sleep in an upright position
- Avoid trigger positions
2. Medication (symptomatic):
- Antihistamines (dimenhydrinate, meclizine)
- Antiemetics (for vomiting)
- Benzodiazepines (short-term)
- Long-term medication is usually not needed because the maneuvers are the treatment
3. Vestibular rehabilitation:
- Balance exercises
- Adaptation exercises
- For resistant cases
4. Surgery (very rare):
- Posterior canal occlusion (in resistant cases)
Prevention
BPPV cannot be completely prevented but the risk can be reduced:
- Avoid head trauma (use helmets)
- Have your vitamin D level checked
- Stay under regular follow-up (over age 50)
- Keep your migraine attacks under control
- Monitor blood pressure, diabetes, and cholesterol regularly
- Avoid prolonged bed rest
- Do not get up suddenly from bed
- If you have fallen or had a head blow, go to a check-up
During an attack:
- Change position slowly
- Focus on a fixed point
- Sit or lie down if possible
- Do not drive
- Stay away from heights
- After it is controlled, perform Brandt-Daroff exercises