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Benign Paroxysmal Positional Vertigo

What Is It, Causes, Treatment, and More

Author:Anna Hernádez, MD

Editors:Alyssa Haag,Stefan Stoisavljevic, MD,Kelsey LaFayette, DNP, ARNP, FNP-C

Illustrator:Jessica Reynolds, MS

Copyeditor:Stacy Johnson, LMSW


What is benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo, or BPPV, is a relatively common disorder of the inner ear characterized by recurrent episodes of vertigo triggered by changes in head position. Paroxysmal is a sudden recurrence of or increased symptoms of a disease or disorder. Vertigo is the spinning sensation that occurs when there is a mismatch between the vestibular apparatus (i.e., the part of the inner ear responsible for balance) and other sensory systems, like sight or proprioception. When vertigo is caused by damage to the vestibular apparatus, it is called peripheral vertigo. In contrast, when it is due to damage to the central nervous system, it is called central vertigo

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What causes benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo. It is caused by a problem with the vestibular apparatus, which includes the otolith organs, named utricle and saccule, and the three semicircular canals. The utricle and saccule are the sensory organs responsible for static balance. They contain a fluid called endolymph and sensory hair cells that detect changes in head position with horizontal or vertical acceleration. A gelatinous layer called the otolithic membrane, which has tiny ear stones called otoliths, sits on the hair cells. The otoliths are essential for the proper functioning of the otolithic membrane, as they help deflect movement in the hair cells to process changes in linear acceleration. On the other hand, the semicircular canals detect changes in head rotation and are responsible for dynamic balance. Like the utricle and saccule, the semicircular canals contain sensory hair cells; however, they respond primarily to the movement of endolymph inside the canals.

BPPV occurs when otoliths move from their usual position in the utricle and into the semicircular canals, most commonly, the posterior canal. The otoliths then disrupt the normal flow of endolymph in the canals when the head moves in a specific direction. Without normal endolymphatic flow, the semicircular canals can’t detect movement. This causes the spinning sensation of vertigo and involuntary eye movements, known as nystagmus.

Although most cases of BPPV occur without any underlying identifiable cause, known risk factors include age over 50, previous history of migraine, head injury, inner ear surgery, infections affecting the inner ear (e.g., labyrinthitis), and other balance disorders, like vestibular neuritis.

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What are the signs and symptoms of benign paroxysmal positional vertigo?

Symptoms of benign paroxysmal positional vertigo include recurrent vertigo episodes triggered by specific and predictable head movements, such as rolling over in bed. Vertigo is often described as the illusion of self-motion or movement of the surrounding environment that leads to a sensation of spinning or swaying. These episodes generally last less than one minute and can accompany nausea or vomiting. Although most individuals with BPPV have few or no symptoms between episodes, they may experience a mild general sensation of instability. Unlike with other vestibular disorders, hearing loss and tinnitus are usually absent in BPPV.

How is benign paroxysmal positional vertigo diagnosed?

The diagnosis of benign paroxysmal positional vertigo can be suspected based on the individual’s clinical presentation and is confirmed by exacerbation of vertigo or nystagmus during a provoking maneuver, like the Dix-Hallpike maneuver.

To perform the Dix-Hallpike maneuver, the examiner extends the neck of the individual and turns it to one side while they are seated. Then, the examiner rapidly places the individual in a lying position so that their head hangs over the edge of the bed. After 30 seconds, there might be nystagmus or vertigo symptoms. If no nystagmus or vertigo symptoms occur, the individual is returned to the upright position. The maneuver is then repeated for the other side to identify the affected ear. 

How is benign paroxysmal positional vertigo treated?

The treatment of BPPV is the Epley maneuver, a particle repositioning maneuver aimed at guiding the lost ear stones back into the utricle.

To perform the Epley maneuver, the examiner grasps the head of the individual on both sides and rapidly positions them to the lying position with the affected ear pointing downwards. Then, the examiner immediately rotates their head to the other side so that the affected ear points upwards. Next, the individual is asked to turn their body and rotate their head until their nose points towards the floor. The individual should hold each position for at least 30 seconds. The individual is returned to the upright position to end the maneuver.

Because BPPV can recur, individuals are taught a modified version of the Epley maneuver that an individual can complete at home. First, in the sitting position, the individual turns their head about 45 degrees to the affected side. Then, the individual lies down supine and waits for 30 seconds. Next, without raising the head, the individual turns their head  90 degrees to the unaffected side and stays for 30 seconds. Next, they may turn their body 90 degrees to the unaffected side and wait another 30 seconds. Finally, they are told to sit up on one side. It is recommended that the modified Epley maneuver be performed three times a day until there are no symptoms for at least 24 hours.

If the Epley maneuver is ineffective, other particle repositioning maneuvers like the Semont maneuver can be done. In rare cases where BPPV persists and severely impacts the quality of life, surgery may be done to block the posterior semicircular canal and prevent ear stones from moving around. 

What are the most important facts to know about benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo (BPPV) is a common cause characterized by brief episodes of vertigo triggered by changes in head position. BPPV occurs due to the movement of tiny ear stones within the inner ear's semicircular canals, which generally detect rotational head movements. The episodes of vertigo may be accompanied by nausea and vomiting and can recur periodically for weeks to months. Diagnosis is confirmed by exacerbation of vertigo or nystagmus during the Dix-Hallpike maneuver. Treatment consists of canalith repositioning procedures to guide the lost ear stones back to their original location.

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Related links

Anatomy and physiology of the ear
Vestibular transduction
Vertigo: Pathology review

Resources for research and reference

Hornibrook, J. (2011). Benign paroxysmal positional vertigo (BPPV): History, pathophysiology, office treatment and future directions. International Journal of Otolaryngology, 2011, 835671. https://doi.org/10.1155/2011/835671

Palmeri, R., Kumar, A. Benign paroxysmal positional vertigo. [Updated 2022 Jan 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470308/

Purves, D., Augustine, G.J., Fitzpatrick, D., et al., editors. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001. The otolith organs: The utricle and sacculus. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10792/