Benign Paroxysmal Positional Vertigo (BPPV)

What is BPPV?

Benign paroxysmal positional vertigo, or BPPV, is a common inner ear problem that causes short bursts of dizziness when you move your head into certain positions. It happens when tiny crystals inside your inner ear come loose and move to where they shouldn't be within the inner ear canals, sending confusing signals to your brain.

Symptoms of BPPV

The main symptom is vertigo, a spinning or whirling sensation, a bit like getting off a merry-go-round fairground ride. It's usually brief, often lasting between five and 30 seconds, only occasionally going on for up to a minute or two.

A sensation of you, or your surroundings, spinning or whirling You may also have the following sensations at the same time:

• Feeling like you're falling, or being thrown backwards, as you lie down or sit up
• Nausea or vomiting
• Sweating, or a feeling of panic
• Fast, uncontrolled eye movements (nystagmus)
• General unsteadiness or fuzzy dizziness between episodes

Common triggers include lying down flat, sitting up from lying down, rolling over in bed, tipping your head back, and looking up or bending down, especially while also turning your head to one side.

Causes of BPPV and who's at risk

BPPV happens when tiny calcium crystals, sometimes called ear rocks, come loose from a jelly-like patch inside your inner ear and drift into one of the fluid-filled canals that help you balance. Head movement then makes them shift about, which sends mixed messages to your brain and triggers vertigo.

In roughly half to two-thirds of cases, there's no clear reason why this happens. Where a cause can be identified, it's often linked to one of the following below.

Who is at risk

• Getting older, since it becomes progressively more common with age
• Being female
• A head injury, including from falls, car accidents, or ear surgery
• An inner ear infection, such as labyrinthitis, or a bout of vestibular neuritis
• Migraine, or Ménière's disease
• Osteoporosis, low bone density, or a vitamin D deficiency
• Lying in bed for a long time, for example during an illness, after surgery, or through a preferred sleeping position.

Are there different types of BPPV?

BPPV is classified by which of the three fluid-filled canals in your inner ear the loose crystals have drifted into:

• Posterior canal BPPV: by far the most common type
• Lateral (or horizontal) canal BPPV: less common, and needs a different repositioning technique
• Anterior (or superior) canal BPPV: rare

Up to 1 in 10 cases affect both ears at once. Rarely, instead of floating freely, the crystals stick to the jelly itself. This is called cupulolithiasis, and it tends to cause longer episodes of vertigo, up to two minutes, which can be harder to treat.

How is BPPV diagnosed?

Between episodes, there's often nothing unusual to find on examination, and diagnosis relies on your description of the vertigo and its triggers, along with ruling out other causes of dizziness.

The main test is the Dix-Hallpike manoeuvre, which should be carried out by a clinician. You sit on the examination couch, and your clinician turns your head 45 degrees to one side before helping you lie back quickly with your head tipped slightly backwards. If you have BPPV, this brings on vertigo along with the characteristic eye movements, usually settling within a minute.

If a sideways (horizontal) canal is suspected, your clinician may instead use a head-roll test, turning your head from side to side while you lie on your back and watching for the same kind of eye movements.

How is BPPV treated?

The first step is usually simple reassurance and an explanation of what's happening, since understanding BPPV can make the episodes feel less frightening. Many cases settle by themselves, often within a few weeks, as the crystals gradually dissolve or disperse.

Repositioning manoeuvres

For most people, the main treatment is a repositioning manoeuvre, called the Epley manoeuvre, which guides the crystals back to where they belong. It's usually carried out by a clinician, though you may be shown how to repeat parts of it yourself. For BPPV affecting the right ear, it generally follows this sequence:

1. You sit upright, and your clinician turns your head 45 degrees towards the affected ear
2. You're then laid back quickly, with your head tipped back slightly, and held in this position for 20 to 30 seconds
3. Your head is turned 90 degrees to the opposite side and held for about 20 seconds
4. Your head and body are turned again, so you end up nearly facing the floor, and held for a further 20 to 30 seconds
5. You're brought back up to sitting, which completes the manoeuvre.

This is highly effective, easing symptoms in around 9 in 10 people, though some need more than one session. A related technique, the Brandt-Daroff exercise, can sometimes be practised at home instead, following instructions from a clinician.

Medication

Medicines don't fix the underlying problem, since they can't move the crystals back into place. Your GP may still prescribe something for a short time to ease severe nausea or spinning during a bad episode, but this isn't recommended for long-term use, as it can slow your recovery.

Vestibular rehabilitation

If dizziness or balance problems continue after the vertigo itself has settled, a physiotherapist specialising in managing vestibular disorders can offer exercises to retrain your balance system.

Surgery

Surgery is rarely needed, and is only considered for the small number of people whose symptoms don't improve after repeated repositioning manoeuvres. Options include sealing off the affected canal, and carry a risk of hearing loss, so are very much a last resort.

When should I see a doctor?

See your GP if you have sudden vertigo, particularly with feeling lightheaded or nauseated, so they can work out the cause and refer you on if needed.

BPPV does not cause constant dizziness that's unaffected by movement, and it shouldn't affect your hearing or cause fainting, headaches, numbness or pins and needles, trouble speaking, or difficulty coordinating your movements. If you notice any of these, see your GP, as another condition may be responsible.

If you have sudden, unexpected and disabling attacks of dizziness, the DVLA advises that you should stop driving and speak to your GP. You should also tell your employer if BPPV could put you or others at risk at work, for example if your job involves ladders, machinery or driving.