Topic Overview

What is benign paroxysmal positional vertigo (BPPV)?

Vertigo is the feeling that you are spinning or the world is spinning around you. Benign paroxysmal positional vertigo is caused by a problem in the inner ear. It usually causes brief vertigo spells that come and go.

For some people, BPPV goes away by itself in a few weeks. But it can come back again.

BPPV is not a sign of a serious health problem.

What causes BPPV?

Benign paroxysmal positional vertigo (BPPV) is caused by a problem in the inner ear. Tiny calcium "stones" inside your inner ear canals help you keep your balance. Normally, when you move a certain way, such as when you stand up or turn your head, these stones move around. But things like infection or inflammation can stop the stones from moving as they should. This sends a false message to your brain and affects your balance.

What are the symptoms?

The main symptom is a feeling that you are spinning or tilting when you are not. This can happen when you move your head in a certain way, like rolling over in bed, turning your head quickly, bending over, or tipping your head back.

BPPV usually lasts a minute or two. It can be mild, or it can be bad enough to make you feel sick to your stomach and vomit. You may even find it hard to stand or walk without losing your balance.

How is BPPV diagnosed?

You and your doctor will talk about your symptoms. Your doctor will do a full physical examination and will test your nervous system to see if there’s a problem with how your nerves send messages to your brain. Your doctor may be able to tell that you have BPPV by watching how your eyes move as you turn your head and lie back. This is called the Dix-Hallpike test.

There are other things that can cause vertigo, so you may have other tests too.

How is it treated?

BPPV usually goes away by itself within a few weeks. Over time, your brain will likely get used to the confusing signals it gets from your inner ear. But you can do some simple exercises that might make the vertigo go away faster.

One kind of exercise for BPPV can move the calcium stones in a way that they don't trigger vertigo. Another kind of exercise can try to train your brain to get used to the confusing vertigo signals.

Medicine can help with severe vertigo that makes you sick to your stomach. But using this kind of medicine can also make BPPV take longer to go away. Only you know whether you feel sick enough that it is worth it to take medicine (and possibly have vertigo longer).

Be extra careful so that you don't hurt yourself or someone else if you have a sudden attack of vertigo.

• Do not drive or cycle if there is any chance that vertigo could strike and make you lose control. (This depends on what kind of movement triggers vertigo for you.)
• At home, keep floors and walkways free of clutter so you don't trip.
• Avoid heights.
• Don't use tools or machines that could be dangerous if you suddenly lose your balance.

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Cause

Benign paroxysmal positional vertigo (BPPV) is caused by a problem in the inner ear. Tiny calcium "stones" inside your inner ear canals help you keep your balance. Normally, when you move a certain way, such as when you stand up or turn your head, these stones move around. But things like infection or inflammation can stop the stones from moving as they should. This sends a false message to your brain and affects your balance.

Symptoms

The main symptom of benign paroxysmal positional vertigo (BPPV) is the feeling that you or your surroundings are spinning, whirling, or tilting. This sensation is called vertigo.

It is important to understand the difference between vertigo and dizziness. People often use those two terms as if they meant the same thing. But they are different symptoms and they may point to different problems.

• Vertigo is the feeling that you are spinning or the world is spinning around you. It happens when your body's balance sensory systems disagree about what kind of movement they sense. You may find it hard to walk or stand. You may even lose your balance and fall. If your vertigo is bad enough, you may also have nausea and vomiting.
• Dizziness is not a feeling that you are spinning. It is a woozy or unsteady feeling.

To find out whether your vertigo is caused by BPPV, your doctor will want to find out what causes it, how bad it is, and how long it lasts. With BPPV:

• Tilting the head, looking up or down, rolling over in bed, or getting in and out of bed causes vertigo.
• It begins a few seconds after you move your head.
• It usually lasts less than a minute. The spinning sensation may be mild, or it may be bad enough to cause nausea and vomiting.
• Vertigo becomes less noticeable each time you repeat the same movement. After 3 to 4 repeats, the movement may no longer cause vertigo. Several hours may pass before the same movement again causes vertigo.

What Happens

Benign paroxysmal positional vertigo (BPPV) causes a whirling, spinning sensation even though you are not moving. If the vertigo is bad, it may also cause nausea or vomiting. The vertigo attacks happen when you move your head in a certain way, such as tilting it back or up or down, or by rolling over in bed. It usually lasts less than a minute. Moving your head to the same position again may trigger another episode of vertigo.

BPPV often goes away without treatment. Until it does, or is successfully treated, it can repeatedly cause vertigo with a particular head movement. Sometimes it will stop for a period of months or years and then suddenly come back.

What Increases Your Risk

Scientists think you're more likely to develop benign paroxysmal positional vertigo (BPPV) if you have one of these conditions:

• You are an older adult.
• You have a head injury.
• You have an inflammation of the inner ear or of the nerve that connects the inner ear to the brain, a condition called vestibular neuritis.
• You have ear surgery.

If you've had one episode of vertigo caused by BPPV, you are likely to have more.

When To Call a Doctor

Call your doctor immediately if you have the spinning, whirling sensation of vertigo together with any of the following:

• A head injury
• Complete, sudden hearing loss
• Weakness in an arm or leg
• Blurred or double vision
• Difficulty speaking
• Persistent numbness or tingling anywhere on your body

Call your doctor to schedule an appointment if:

• This is the first time you have had an attack of vertigo.
• You have a low-pitched roaring, ringing, or hissing sound in your ear, especially if you have not had this before. This is called tinnitus.
• You have frequent or severe episodes of vertigo that interfere with your activities.
• You have an attack of vertigo that is different from what you were told to expect.
• You need medicine to control nausea and vomiting.

Watchful Waiting

If your symptoms suggest benign paroxysmal positional vertigo (BPPV), watchful waiting may be appropriate. Over time BPPV may go away on its own. If it interferes with your normal daily activities or causes nausea and vomiting, you may need treatment.

Who To See

Ask your family doctor or general practitioner about treating benign paroxysmal positional vertigo. You may be referred to an otolaryngologist or a neurologist.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Examinations and Tests

Benign paroxysmal positional vertigo (BPPV) is diagnosed with a detailed physical and neurologic examination and from your medical history. But diagnosing the cause of the spinning, whirling sensation of vertigo can be difficult. Several diseases, the side effects of medicines, and head injuries can also cause vertigo.

A Dix-Hallpike test may be done to help your doctor find out the cause of your vertigo. During this test, he or she will carefully observe any involuntary eye movements. This will help your doctor know whether the cause of your vertigo is inside your brain, your inner ear, or the nerve connected to your inner ear. The Dix-Hallpike test also can help your doctor find out which ear is affected.

Other tests may be done to help diagnose your condition:

• Electronystagmography, which attaches small wires to your face that measure eye movements. It looks for the special eye movements that happen when the inner ear is stimulated. The pattern of eye movements can point to the location of the cause of the vertigo, such as the inner ear or the central nervous system.
• Imaging tests, such as magnetic resonance imaging of the head (MRI) or computed tomography of the head (CT scan). These tests may be done if the symptoms and examination findings could be caused by a brain problem.
• Hearing testing to detect hearing loss. A special hearing test can determine whether the nerve from the inner ear to the brain is working correctly. Hearing loss with vertigo usually points to a problem other than BPPV, such as Ménière's disease or labyrinthitis.

Treatment Overview

Benign paroxysmal positional vertigo (BPPV) may go away in a few weeks by itself. If treatment is needed, it usually consists of head exercises (Semont and Epley manoeuvres). These exercises will move the particles out of the semicircular canals of your inner ear to a place where they will not affect your balance.

Over time, your brain may react less and less to the confusing signals triggered by the particles in the inner ear. This is called compensation. Compensation occurs most quickly if you continue normal head movements, even though doing so causes the whirling sensation of vertigo. A Brandt-Daroff exercise may also be done to speed the compensation process. This exercise takes you from sitting to lying on the side that causes the worst vertigo. You'll remain in this position until either the vertigo goes away or until 30 seconds have passed. This movement is then repeated on the other side. These exercises are done twice a day for several weeks to months, or until the vertigo goes away.

Medicines called vestibular suppressants (such as antihistamines, sedatives, or scopolamine) reduce vertigo and may be tried if your symptoms are severe. But using medicines to control vertigo often extends the time needed for compensation to occur.

Antiemetic medicines may also be used to reduce nausea and vomiting that can occur with vertigo.

In rare cases, surgery may be used to treat BPPV.

Prevention

In most cases, benign paroxysmal positional vertigo (BPPV) cannot be prevented. However, some cases may result from head injuries. Wearing a helmet when bicycling, motorcycling, playing baseball, or doing other sports activities can protect you from a head injury and BPPV.

Home Treatment

You can reduce the whirling or spinning sensation of vertigo when you have benign paroxysmal positional vertigo (BPPV) by taking these steps:

• Use two or more pillows at night.
• Avoid sleeping on your side with the ear causing the problem facing down.
• Get up slowly in the morning and sit on the edge of the bed for a moment before standing.
• Avoid leaning over to pick things up or tipping your head far back to look up.
• Be careful about reclining, such as when you are in the dentist's chair or having your hair washed at a hair salon.
• Be careful about playing sports that require you to turn your head, lean over, or lie flat on your back.

You can also help yourself by doing balance exercises and taking safety precautions.

Stay safe when you have balance problems by adding grab bars near the bathtub and toilet and keeping walking paths clear. This may prevent accidents and injuries.

Balance exercises for vertigo, such as standing with your feet together, arms down, and slowly moving your head from side to side, may help you keep your balance and improve symptoms of vertigo.

If your doctor treated you with a Semont or Epley manoeuvre, you may be instructed to restrict your head movement for about a day. Do this by sleeping with your head propped up, not sleeping on the affected side, and not tipping your head too far up or down.

If your doctor has you try the Brandt-Daroff exercise to help your brain adjust, you will need to do the exercises at home several times a day, possibly for weeks. The exercises will allow your brain to get used to the abnormal balance signals triggered by the particles in the inner ear.

Staying as active as possible usually helps the brain adjust more quickly. But that can be hard to do when moving is what causes your vertigo. Bed rest may help, but it usually increases the time it takes for the brain to adjust.

Medications

Medicines do not cure benign paroxysmal positional vertigo (BPPV). But they may be used to control severe symptoms, such as the whirling, spinning sensation of vertigo and the nausea and vomiting that may occur.

Medication Choices

Medicines to reduce the whirling sensation of vertigo are called vestibular suppressants. They include:

• Antihistamines, such as Gravol (dimenhydrinate), Bonamine (meclizine), Benadryl (diphenhydramine).
• Scopolamine, also known as Transderm-V.
• Sedatives, such as Valium (diazepam) or Clonapam (clonazepam).

Antiemetic medicines may be used if you have nausea or vomiting along with the vertigo.

What To Think About

Medicines that calm the inner ear (vestibular suppressants) may also slow down the brain's ability to adjust to the abnormal balance signals triggered by the particles in the inner ear. They should be taken only for 1 to 2 weeks to control severe symptoms.

Surgery

Ear surgery is an option for treating benign paroxysmal positional vertigo (BPPV) only in severe cases when other treatments have not worked.

Other Treatment

Exercises are used to treat benign paroxysmal positional vertigo (BPPV). These exercises help the particles in the semicircular canals of your inner ear move around, so that they don't affect your balance. Although the exercises usually stop the vertigo for months or years, the problem may return and cause your symptoms to come back.

Other Treatment Choices

Exercises that may be used to treat BPPV include:

• Semont manoeuvre and modified Epley manoeuvre. These exercises often cure BPPV by moving the particles in your inner ear so that they do not affect your balance. During these exercises, your doctor will help you hold your head in a series of positions. Often, one treatment is enough. You may be taught to do these exercises on your own at home.
• Brandt-Daroff exercise. This exercise may be tried if the Semont or modified Epley manoeuvres do not work. During this exercise, you will repeatedly go from a sitting position to a lying position until the vertigo stops. This exercise may help speed your brain's ability to adjust to the conflicting balance signals it is getting. You need to do these exercises several times a day for weeks for them to work.

What To Think About

These exercises can get rid of BPPV symptoms. The Semont and modified Epley manoeuvres usually are more comfortable than the Brandt-Daroff exercise, and they work faster—in one or two treatments rather than being repeated several times a day for weeks. So these manoeuvres have become the first line of treatment.¹

Other Places To Get Help

Organizations

Related Information

• Dizziness: Light-headedness and Vertigo
• Labyrinthitis
• Ménière's Disease
• Vestibular Neuritis

References

Citations

1. 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.

Other Works Consulted

• Furman JM, Hain TC (2004). Do try this at home: Self-treatment of BPPV. Neurology, 63(1): 8–9.
• Hillier SL, Hollohan V (2007). Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews (4).
• Hilton M, Pinder D (2004). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews (2). Oxford: Update Software.
• Radtke A, et al. (2004). Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs. Epley procedure. Neurology, 63(1): 150–152.
• Tanimoto H, et al. (2005). Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology, 65(8): 1299–1300.
• von Brevern M, et al. (2004). Migrainous vertigo presenting as episodic positional vertigo. Neurology, 62(3): 469–472.
• Von Brevern M, et al. (2006). Short-term efficacy of Epley's manoeuvre: A double-blind randomised trial. Journal of Neurology, Neurosurgery, and Psychiatry, 77(8): 980–982.

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