Benign paroxysmal positional vertigo (BPPV) is a condition often seen in primary care practices. Basically, it is dizziness that is triggered by certain head movements such as lying down or rolling over in bed. BPPV is a peripheral vestibular disorder that can negatively affect quality of life and daily functioning and can increase the risk of falls. BPPV is caused by otolith (an inner ear structure that detects acceleration) particles that become lodged in any of the three inner ear semicircular canals (anterior, posterior, and horizontal), but most commonly affect the posterior canal. The semicircular canals are responsible for maintaining balance. When the head moves in the plane of the involved canal, these tiny otolith particles move in response to gravitational forces, generating fluid motion within the inner ear. This fluid motion alters vestibular signaling, which causes involuntary eye movement (nystagmus, a side-to-side twitching of the eyeball) and dizziness typically described as vertigo.
BPPV is a common condition, with age as the primary risk factor. A study done in Germany estimated a cumulative incidence of 10% by age 80 years. The prevalence increases with age likely because the otolith becomes more friable (brittle) with age. BPPV is also associated with trauma and traumatic brain injury. BPPV typically presents as brief (< 1 minute) recurrent episodes of vertigo triggered by some head movements. Some patients with BPPV report nonspinning dizziness (lightheadedness or unsteadiness without vertigo) or continuous dizziness with positional worsening instead of only brief, isolated positionally triggered symptoms. Nystagmus, which can cause double vision, occurs with the onset of vertigo in patients whose dizziness is positional.
An in-office test, called the Dix-Hallpike test, is the criterion-standard test to diagnose BPPV. This involves turning the patient’s head 45 degrees to one side and then lowering them backward to a position with the head extended 20 degrees to 30 degrees below horizontal, which can be done with pillows or over the end of the table. The test is positive if it triggers transient nystagmus lasting about 10 to 20 seconds. Persistent (not transient) and downbeat, rather than horizontal, nystagmus on this test suggests a structural brain disorder.
The Epley maneuver, endorsed by multidisciplinary clinical practice guidelines, involves specific head turns and body movements to guide the otolith particles out of the posterior semicircular canal, and is the most studied and effective treatment for BPPV. The key steps of the Epley maneuver include extending the patient’s head at least 20 degrees below the horizontal plane when in the lying-back position (the same position as the Dix-Hallpike test) and staying in each position for at least 20 seconds. In clinical trials measuring outcomes at 1 week, the Epley maneuver led to symptom resolution in 32% to 80% of patients. The Epley maneuver is often used in ER settings for patients suspected of having BPPV, and patients can be taught to perform it at home for self-treatment.
There are no medications that will improve BPPV symptoms. While in primary care settings meclizine, an antihistamine used to treat dizziness, is often prescribed, it is ineffective for BPPV and may cause unnecessary sedation. Patients with refractory BPPV that do not respond to the Epley maneuver should be referred to a vestibular specialist.
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