Positional Vertigo: Understanding the Causes, Symptoms, Diagnosis, and Treatment

What are the most common causes of positional vertigo that causes the sensation of spinning and intense dizziness.

Benign Paroxysmal Positional Vertigo (BPPV) or Benign Positional Vertigo for short, is a common vestibular disorder. Studies show that it accounts for approximately 20-30% of all vestibular complaints in clinic¹. It is characterized by recurring episodes of dizziness or vertigo and nystagmus, triggered by specific head movements. Although it can be disorienting and unsettling, BPPV is generally a condition that can be effectively managed with appropriate diagnosis and treatment. In this article, we will explore the various aspects of BPPV, including its symptoms, triggers and causes, diagnosis and treatment options, and tips for managing and preventing episodes.

In This Article

• What is Benign Paroxysmal Positional Vertigo (BPPV)?

• Symptoms of Positional Vertigo
• Can Positional Vertigo Come and Go?
• What is the Cause of Benign Paroxysmal Positional Vertigo?
• What Can I do for Benign Paroxysmal Positional Vertigo?
• Diagnosis
• Treatment
• How Do You Fix Benign Paroxysmal Positional Vertigo?
• What Should You Do After Treatment for Positional Vertigo?
• Does Benign Paroxysmal Positional Vertigo Ever Go Away?
• Tips for Managing Positional Vertigo at Home
• The Home Epley Maneuver
• Brandt-Daroff Exercises
• Summary

What is Benign Paroxysmal Positional Vertigo (BPPV)?

BPPV is a disorder of the inner ear that arises when small calcium carbonate crystals called otoconia become dislodged from the their normal position in the utricle¹.

The utricle is a sensory organ at the base of each semicircular canal within the inner ear. There are three semicircular canals and they are responsible for sensing rotational movement. They play a crucial role in our ability to maintain our balance.

Symptoms of Positional Vertigo

The primary symptom of BPPV is vertigo, which is a spinning sensation or a feeling of being off balance.

Other common symptoms include:

• Brief episodes of dizziness lasting for a few seconds to a few minutes
• Nausea and vomiting during severe episodes
• Loss of balance and unsteadiness
• Blurred vision or nystagmus (involuntary eye movements)
• Lightheadedness or faintness
• Sensation of being pulled to one direction¹

BPPV can sometimes cause related consequences, such as tinnitus (ringing or buzzing in the ears). The symptoms may last up to a minute and usually subside once the crystals have settled back down into position.

Can Positional Vertigo Come and Go?

Unfortunately, even after treatment, positional vertigo may re-occur weeks or even years later, if another crystal dislodges into your semicircular canals. If you have BPPV, anytime there is a change in the position of the head, the crystals can move and trigger an attack of vertigo and dizziness. These include common daily movements like:

• Moving from lying down to sitting up in bed
• Rolling over in bed
• Looking upwards
• Bending forwards to pick something up

Symptoms may be more frequent at times, if the otoconia do not find their way back into the utricle. This can be disturbing and fear-inducing since you might feel fine one day, but then the symptoms return again the next day.

What is the Cause of Benign Paroxysmal Positional Vertigo?

The exact cause of BPPV is often unknown, but it can occur as a result of:

• Aging
• Head trauma
• Inner ear infections
• Medical conditions affecting the inner ear, such as Ménière's disease

It may even develop spontaneously without an identifiable cause, in some cases¹.

What Can I Do for Benign Paroxysmal Positional Vertigo?

How Do You Fix Benign Paroxysmal Positional Vertigo?

Positional vertigo can be successfully treated without medicines, surgery or special equipment, using the Epley maneuver².

The Epley maneuver is a series of head and body movements performed by a healthcare professional. It helps to guide the otoconia out of the affected semicircular canal, repositioning them back into the utricle where they no longer cause symptoms.

While lying back after the Dix-Hallpike assessment, the doctor will:

1. Turn your head to the other side and hold for 30 seconds
2. Then ask you to roll onto the side, while turning your head to face the floor - holding for 30 seconds
3. Finally, you will swing your legs off the side of the bed to sit back up, while holding your head facing downwards for 30 seconds

Symptoms usually resolve after the maneuver has been performed, but sometimes it can take a few tries before the procedure works. In these cases, your doctor may prescribe some of these movements for you to repeat at home. In some cases, medications may be prescribed to alleviate associated symptoms such as nausea and dizziness².

What Should You Do After Treatment for Positional Vertigo?

For the remainder of the day after the Epley maneuver treatment, it is best to avoid:

• Tilting your head back
• Bending far forward (for example, putting on shoes)

Also avoid sleeping on the affected side for several days. It can help to prop yourself up on several pillows overnight.

Does Benign Paroxysmal Positional Vertigo Ever Go Away?

BPPV can be successfully managed and often resolves spontaneously over time, particularly in cases without an underlying cause. The repositioning maneuvers and treatments mentioned above have a high success rate in providing relief. However as mentioned before, it is possible for BPPV to recur, especially in individuals who are prone to developing otoconia displacement.

Tips for Managing Positional Vertigo at Home

1. It is important to stay active and perform exercises that promote balance, and your healthcare provider might prescribe some vestibular rehabilitation exercises for you to do at home.
2. Caution should be used during self-treatment as your dizziness and nausea may get worse during the movement. It is therefore strongly recommended that you have someone with you while you are performing the exercises for safety and reassurance.
3. The most effective exercise for you will depend upon which ear is affected, and more specifically, which semicircular canal is affected. Your healthcare provider will diagnose this and recommend which exercises to perform.

Here are some examples of at home vestibular rehab exercises:

Summary

The symptoms of BPPV can be very disturbing since their onset may be quite sudden and they may cause people to lose their balance or even fall out of bed. Thankfully the cause is benign as a result of calcium carbonate crystals moving around the semicircular canals.

It is crucial to consult with a healthcare provider for an accurate diagnosis and appropriate treatment plan. Treatment is non-invasive and symptoms usually subside quickly afterwards.

References

¹ De Stefano A, Dispenza F, Suarez H, Perez-Fernandez N, Manrique-Huarte R, Ban JH, et al.(2014). A multicenter observational study on the role of comorbidities in the recurrent episodes of benign paroxysmal positional vertigo. Auris Nasus Larynx. 41:31–6. 10.1016/j.anl.2013.07.007

² Benign Paroxysmal Positional Vertigo (BPPV). Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/benign-paroxysmal-positional-vertigo-bppv, on 15 May 2023.

³ Fife TD, et al. (2008). Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70(22): 2067–2074.

⁴ Home Epley Maneuver. Retrieved from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/home-epley-maneuver, on 15 May 2023.