What is Benign Paroxysmal Positional Vertigo (BPPV)?

Vertigo is when you feel motion even though you are not moving. This can show up as feeling unsteady, like you’re spinning, tilting, or swaying. It’s often grouped under the umbrella term “dizziness,” which is responsible for over three million visits to the emergency department each year. But using the term “dizziness” can be confusing and misleading because it can mean different things to different people. Vertigo can be caused by issues in the inner ear or other body structures, or it can come from other center-based problems.

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo that stems from the inner ear, and it’s responsible for over half of all vertigo cases. Hence, it’s estimated that at least 20% of patients who come in complaining of vertigo actually have BPPV. This number could be higher because BPPV often gets misdiagnosed. It’s essential to distinguish BPPV from other causes of vertigo because the potential causes could range from harmless to life-threatening. Because the term “dizziness” is so vague and can lead to confusion, doctors should ask patients to explain what they’re feeling without using the word “dizziness”.

Barany first identified BPPV in 1921. They found that changes in position could lead to vertigo and uncontrolled eye movements and connected these symptoms to the organs that help control our balance. In 1952, Dix and Hallpike expanded on this during their testing and located the source of the issue in the ear itself.

What Causes Benign Paroxysmal Positional Vertigo (BPPV)?

Benign paroxysmal positional vertigo, or BPPV, happens when tiny calcium-carbonate crystals called otoconia shift location within the fluid-filled tubes in our inner ear. These otoconia play a crucial role in our balance system by assisting the utricle, a part of the inner ear, in sensing head movements like tilting, turning, and speeding up or slowing down.

In around 50% to 70% of BPPV cases, there is no identifiable cause. These cases are often described as primary or idiopathic BPPV. The rest are referred to as secondary BPPV and are usually linked to an existing health issue. These could include head injuries, nerve inflammation in the ear (vestibular neuronitis), inflammation of the inner ear (labyrinthitis), Ménière disease, migraines, reduced blood supply (ischemia), and side effects from medical treatments. The most common cause of secondary BPPV is a head injury, accounting for 7% to 17% of all BPPV cases. These injuries can dislodge many otoconia, resulting in BPPV. Viral infections in the inner ear can also cause BPPV, making up to 15% of all cases.

Ménière disease, a disorder of the inner ear, is linked to 0.5% to 31% of BPPV cases. Some patients with Ménière disease have been observed to have BPPV as well. It might be due to injury to the utricle or blockage in the inner ear.

Migraines also seem to have a strong connection to BPPV. Studies have found an increased rate of migraines in patients with BPPV and BPPV reoccurrences in migraine patients. The possible cause might be a spasm in the inner ear’s blood vessels, as spasms often accompany migraines.

Lastly, BPPV can also occur after surgery on the inner ear, possibly due to damage to the utricle releasing otoconia.

Risk Factors and Frequency for Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo, also known as BPPV, typically affects people between the ages of 50 and 70. However, it can happen at any age, though it’s seldom seen in those under 35 unless they’ve had a head injury.

BPPV has an annual incidence of 64 per 100,000 in the United States, equating to roughly 200,000 new cases each year.
The incidence rate increases by 38% every decade.
Studies discovered a 9% occurrence rate in older patients presenting with balance issues, suggesting BPPV is often unrecognized.
The lifetime incidence of BPPV in the adult European population is 2.4%.
It’s more frequent in women, with 3.2% of women experiencing it compared to 1.6% of men.
The one-year occurrence of BPPV is at 1.6%, with an incidence of 0.6% documented.
In Japan, the annual rate of BPPV ranges between 10.7 and 17.3 per 100,000 people.

Signs and Symptoms of Benign Paroxysmal Positional Vertigo (BPPV)

Vertigo, a sensation of feeling off balance, can be caused by issues in the inner ear or brain. Various factors and conditions can trigger it, so a comprehensive personal and medical history, along with a physical examination, is crucial in accurately diagnosing it. Patients should share details about recent viral infections, any trauma, medical procedures, and medication history, as these could provide clues to the cause of the vertigo. It’s also important to note the timing, context, and frequency of the vertigo episodes. Additionally, patients with mood disorders may be prone to developing a particular kind of vertigo caused by an issue in the inner ear, known as Benign Paroxysmal Positional Vertigo (BPPV).

People suffering from BPPV don’t experience dizziness all the time, but can have severe bouts of vertigo triggered by certain head movements. In extreme cases, even slight head movements can cause severe nausea and vomiting. These episodes often start abruptly when changing position suddenly, such as moving from standing to lying down. Usually, these spells disappear within 20 to 30 seconds. However, patients may also describe a persistent “foggy or cloudy” feeling between attacks.

The physical examination for BPPV typically includes what’s called a Dix-Hallpike maneuver. This test involves moving the patient rapidly from a sitting to a lying position with their head turned at a particular angle. This helps to confirm or rule out BPPV. However, if the test is negative, it doesn’t necessarily mean that the patient is free of the condition; it could just mean that there’s no active issue in the inner ear at the time the test is carried out.

Several factors can increase the risk of developing BPPV, including aging, being female, and having certain other conditions such as vestibular neuronitis, labyrinthitis, migraines, Meniere disease, or after head trauma or inner ear surgery. The presence of other disorders can also cause vertigo which lasts for longer durations. Therefore, for accurate diagnosis, it’s crucial to differentiate the symptoms of BPPV from those of other similar conditions.

Inquiry about recent viral infections, trauma, or medication history
Discussion about the timing, context, and frequency of the vertigo episodes
Physical examination including the Dix-Hallpike maneuver
Common risk factors like age, gender, and presence of other conditions
Differentiating symptoms among similar conditions

Testing for Benign Paroxysmal Positional Vertigo (BPPV)

The Dix-Hallpike test is a definitive diagnostic method for a condition known as benign paroxysmal positional vertigo (BPPV), so lab tests are usually not required just for its diagnosis. However, since there is a strong connection between BPPV and inner ear diseases, additional tests might be needed to identify any other potential issues.

Doctors also use the supine lateral head test to diagnose a specific type of BPPV that affects the horizontal canal in your ear. It’s similar to the Dix-Hallpike test. During the test, the patient lays down, and the doctor positions their head 30 degrees below the horizontal line and then rotates it from side to side.

The primary way to diagnose benign paroxysmal positional vertigo is through symptoms and physical examination, so medical professionals often order lab work and imaging tests to rule out other conditions. So, taking a comprehensive medical history and conducting a thorough neurological examination are key. Imaging techniques such as a CT and MRI scan of the head won’t show any abnormalities specific to BPPV, but they may help rule out conditions like stroke, bleeding in the brain, tumors, or other diseases that can cause similar symptoms. If the patient can tolerate it, the Dix-Hallpike test should be done as it could help diagnose which ear canal is affected.

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

When dealing with benign paroxysmal positional vertigo (BPPV), it’s important to start by educating and counseling the patient. If the patient’s BPPV involves the lateral or anterior canals, they might be referred to a specialized care facility. Common treatment for BPPV in the posterior canal involves a particle repositioning maneuver (PRM) which moves particles causing vertigo to an area where they won’t cause symptoms. These maneuvers are easy to perform and can be taught to primary care providers or emergency doctors. However, medications typically used to treat vertigo aren’t usually effective.

The Epley maneuver, which moves the damaging particles from sensitive areas in the ear to less sensitive ones, is another common procedure. To decide which side of the ear to perform the maneuver, the Dix-Hallpike maneuver is used first. If the patient cannot tolerate these procedures, treatments are given to manage the symptoms instead. For example, antihistamines like meclizine can be used to suppress dizziness by calming down the inner ear and its receptors.
Medications are often not very useful because BPPV symptoms tend to come on suddenly and last for a very short time – they’re there and then they’re not – just like the name suggests. However, if dizziness episodes become frequent and interfere with everyday life, medication may be necessary. Nausea and vomiting can also accompany BPPV and can be treated with anti-emetics, such as ondansetron, metoclopramide, or promethazine. If BPPV keeps coming back, a specialist can be consulted for further evaluation.

As mentioned earlier, PRMs are often the first choice of treatment designed to rid the affected ear canal of debris causing vertigo. There are many different types of PRMs, like the Semont or Epley maneuver, or the 3-position maneuver. All of these have been proven to be highly effective in treating BPPV. However, there are some situations where these cannot be used, including severe neck disease, suspected vertebrobasilar disease (issues with specific arteries in the brain), unstable heart conditions, or significant narrowing of the carotid artery.

For most patients, BPPV symptoms will improve with PRMs or go away on their own. However, if symptoms persist, surgery may be needed. There are two types of surgery options, singular neurectomy and posterior canal occlusion, with the latter being preferred as it’s generally safer and more effective.

When trying to diagnose benign paroxysmal positional vertigo (BPPV), a condition that causes brief episodes of mild to intense dizziness, doctors may consider other potential causes or conditions. These include:

Ménière’s disease, a disorder of the inner ear.
Inner ear concussion, which can result after a head injury.
Alcohol intoxication or excessive drinking.
Labyrinthitis or vestibular neuronitis, inflammations of different parts of the ear.
Vascular loop syndrome, a condition where blood vessels cause pressure on the nerve.
Positional nystagmus of central origin, a condition where the eyes make repetitive, uncontrolled movements.
Conditions affecting the nodulus, a part of the brain, such as stroke, Arnold-Chiari malformation, multiple sclerosis, cerebellar degeneration, or intoxication.
Tumors like acoustic neuroma and meningioma.
Vertebral artery insufficiency, a condition where blood flow to the back of the brain is compromised.
Orthostatic hypotension, a form of low blood pressure that happens when you stand up from sitting or lying down.

Doctors would need to rule out these conditions by conducting appropriate tests before diagnosing a patient with BPPV.

What to expect with Benign Paroxysmal Positional Vertigo (BPPV)

One-third of patients experience improvement in their condition at three weeks and most recover at six months. However, instances of the condition returning are quite varied, with one study noting an 18% recollection rate over a decade. Another research found a 15% yearly return rate and a 50% rate at 40 months after treatment.

Less than 1% of people with BPPV will ever require surgery. However, considering that BPPV is a common condition, the absolute number of those needing surgery is quite substantial.

Possible Complications When Diagnosed with Benign Paroxysmal Positional Vertigo (BPPV)

Continuous feelings of nausea and vomiting can be a problem for some people. Making sudden head movements when driving or cycling might set off an episode of benign paroxysmal positional vertigo (BPPV). This could result in a crash. A BPPV episode could lead to severe accidents during work or recreational activities.

Preventing Benign Paroxysmal Positional Vertigo (BPPV)

Patients should be advised to have a follow-up appointment one to four weeks after their treatment. It’s important to let patients know that Benign paroxysmal positional vertigo (BPPV), is not a life-threatening condition and often has a positive outcome. This can help reassure patients that it isn’t a serious condition. They should also be made aware that BPPV can often come back even after successful initial treatment using repositioning techniques, so additional treatment may be required in the future.

Frequently asked questions

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo that stems from the inner ear. It is responsible for over half of all vertigo cases and is often misdiagnosed. BPPV is characterized by changes in position leading to vertigo and uncontrolled eye movements, and it is connected to the organs that help control our balance.

The annual incidence of BPPV in the United States is 64 per 100,000, equating to roughly 200,000 new cases each year.

Signs and symptoms of Benign Paroxysmal Positional Vertigo (BPPV) include: - Severe bouts of vertigo triggered by certain head movements - Nausea and vomiting, which can be severe even with slight head movements - Abrupt onset of episodes, often when changing position suddenly - Spells that usually disappear within 20 to 30 seconds - Persistent "foggy or cloudy" feeling between attacks It's important to note that BPPV doesn't cause dizziness all the time, but rather has episodes triggered by specific movements. These symptoms can be confirmed or ruled out through a physical examination, specifically the Dix-Hallpike maneuver. Additionally, patients with mood disorders may be more prone to developing BPPV.

Benign Paroxysmal Positional Vertigo (BPPV) can be caused by various factors and conditions, including head injuries, nerve inflammation in the ear, inflammation of the inner ear, Ménière disease, migraines, reduced blood supply, side effects from medical treatments, viral infections in the inner ear, and damage to the inner ear during surgery.

Ménière's disease, Inner ear concussion, Alcohol intoxication or excessive drinking, Labyrinthitis or vestibular neuronitis, Vascular loop syndrome, Positional nystagmus of central origin, Conditions affecting the nodulus, Tumors like acoustic neuroma and meningioma, Vertebral artery insufficiency, Orthostatic hypotension

The types of tests that may be needed to properly diagnose Benign Paroxysmal Positional Vertigo (BPPV) include: 1. Dix-Hallpike test: This is a definitive diagnostic method for BPPV and helps determine which ear canal is affected. 2. Supine lateral head test: This test is used to diagnose a specific type of BPPV that affects the horizontal canal in the ear. 3. Comprehensive medical history and neurological examination: These are important to rule out other conditions and identify any potential underlying issues. 4. Lab work and imaging tests: These may be ordered to rule out other conditions and can include CT and MRI scans of the head. 5. Educating and counseling the patient: This is an important step in managing BPPV. 6. Referral to a specialized care facility: If BPPV involves the lateral or anterior canals, the patient may be referred to a specialized care facility. 7. Particle repositioning maneuvers (PRMs): These maneuvers are used to move particles causing vertigo to an area where they won't cause symptoms and are often the first choice of treatment for BPPV. 8. Medications: Medications may be used to manage symptoms, such as antihistamines to suppress dizziness or anti-emetics to treat nausea and vomiting. 9. Surgery: In cases where symptoms persist, surgery may be needed, with options including singular neurectomy and posterior canal occlusion.

Benign Paroxysmal Positional Vertigo (BPPV) can be treated through various methods. The common treatment for BPPV in the posterior canal involves a particle repositioning maneuver (PRM) which moves particles causing vertigo to an area where they won't cause symptoms. The Epley maneuver is another common procedure that moves the damaging particles from sensitive areas in the ear to less sensitive ones. If the patient cannot tolerate these procedures, symptom management treatments such as antihistamines or anti-emetics can be used. In some cases, surgery may be necessary if symptoms persist, with posterior canal occlusion being the preferred option.

The side effects when treating Benign Paroxysmal Positional Vertigo (BPPV) can include: - Dizziness and vertigo during and after the particle repositioning maneuvers (PRMs) such as the Epley maneuver or Semont maneuver. - Nausea and vomiting, which can be managed with anti-emetic medications like ondansetron, metoclopramide, or promethazine. - In some cases, the symptoms may persist and surgery may be needed. The two surgical options are singular neurectomy and posterior canal occlusion, with the latter being preferred due to its safety and effectiveness. - There are certain situations where PRMs cannot be used, such as severe neck disease, suspected vertebrobasilar disease, unstable heart conditions, or significant narrowing of the carotid artery.

One-third of patients with BPPV experience improvement in their condition at three weeks, and most recover within six months. However, there is a varied rate of recurrence, with studies reporting an 18% recollection rate over a decade and a 15% yearly return rate. Less than 1% of people with BPPV will ever require surgery, but considering the commonality of the condition, the absolute number of those needing surgery is substantial.

An otolaryngologist or an ear, nose, and throat (ENT) specialist.

Health Vertigo