Benign paroxysmal positional vertigo (BPPV)

What is benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo (BPPV) is a common inner ear disorder that causes brief episodes of dizziness (vertigo) triggered by changes in head position.

It occurs when tiny calcium carbonate crystals (otoconia) become dislodged from their normal position and move into one of the semicircular canals of the inner ear, disrupting balance signals.

Types of BPPV are classified by the affected canal (posterior, horizontal or anterior), with posterior canal BPPV being the most common.

Symptoms of BPPV

Symptoms are usually brief but can be intense and include:

• Sudden spinning sensation (vertigo), lasting seconds.
• Dizziness when lying down, rolling over in bed, bending forward or looking up.
• Nausea and, occasionally, vomiting.
• Unsteadiness or imbalance.
• Involuntary eye movements (nystagmus) during an episode.

Diagnosis of BPPV

BPPV is diagnosed clinically through a detailed history and physical examination. Positional tests, such as the Dix–Hallpike manoeuvre, are used to reproduce symptoms and observe characteristic eye movements.

Imaging scans are not usually required unless symptoms are atypical or another neurological cause needs to be excluded.

What are the causes of BPPV?

In most cases, BPPV is idiopathic, meaning no clear cause is identified. It may also be associated with:

• Head injury.
• Inner ear infections or inflammation (vestibular neuritis or labyrinthitis).
• Age-related changes affecting the inner ear.
• Prolonged bed rest or reduced mobility.

Can BPPV be prevented?

There is no guaranteed way to prevent BPPV. However, reducing the risk of head injury and maintaining regular physical activity may help. People with recurrent BPPV may be advised on specific positional exercises to recognise and manage symptoms early.

Treatments for BPPV

BPPV is usually treated with canalith repositioning manoeuvres, which use specific head movements to move the displaced crystals back into the correct part of the inner ear.

Commonly used manoeuvres include:

• Epley manoeuvre (most frequently used).
• Semont manoeuvre.
• Barbecue roll manoeuvre (for horizontal canal BPPV).

The choice of manoeuvre depends on which semicircular canal is affected. These treatments are highly effective and often result in rapid symptom relief. Recurrence is common, but repeat treatment is usually successful.

Medications for BPPV

Medication does not treat the underlying cause of BPPV. In some cases, a doctor may prescribe short-term medication to relieve severe nausea or dizziness.

These medications must always be prescribed by a doctor and are not recommended for long-term use, as they do not correct the underlying problem and may delay recovery.

Which specialist should you see?

BPPV is typically managed by an ENT (ear, nose and throat) specialist, audiovestibular physician, or neurologist. Some physiotherapists with specialist vestibular training also treat BPPV using repositioning manoeuvres.