Benign paroxysmal positional vertigo

Overview

BPPV is the most common cause of vertigo - caused by displaced calcium carbonate crystals (otoconia) within the semicircular canals, most often the posterior canal (~85-90% of cases).

Presentation

•Vertigo - sudden, intense rotational sensation lasting seconds (<1 minute)

•Positional trigger - consistently provoked by specific head movements (turning in bed, tilting head back)

•Latency - onset 1-5 seconds after moving into provocative position

•Fatiguability - episodes diminish with repeated testing

•No hearing loss, tinnitus, or continuous dizziness - absence distinguishes from Ménière's and acoustic neuroma

🚨

Red flags suggesting central cause: vertigo lasting hours/days continuously; non-fatiguing or direction-changing nystagmus; neurological signs (diplopia, dysphagia, ataxia); severe headache at onset; nystagmus without head movement. Arrange urgent MRI if any present.

Investigations

•BPPV is a clinical diagnosis - made at the bedside with provocation testing

🥇 First-line

•Dix-Hallpike manoeuvre - diagnostic test of choice for posterior canal BPPV; head turned 45° toward affected ear, rapidly laid back to 30° below horizontal; positive result = upbeat-torsional nystagmus after 1-5 second latency, lasting <60 seconds, fatigues with repetition

•Supine roll test - used if horizontal canal BPPV suspected; head turned 90° to each side; horizontal geotropic nystagmus expected

•MRI brain (posterior fossa sequences) - if atypical features, non-fatiguing nystagmus, neurological signs, or failure to respond to repositioning

•Serum vitamin D - consider in recurrent BPPV; deficiency associated with increased recurrence

Management

•First-line (posterior canal): Epley manoeuvre - particle repositioning; effective in ~80% after a single treatment

•Four-step sequence: sit upright head turned 45° to affected side → recline to 30° below horizontal (hold 30 s) → rotate head 90° to opposite side (hold 30 s) → roll whole body further 90° same direction facing floor (hold 30 s) → sit upright

•Brandt-Daroff exercises - home programme for patient self-management of recurrent episodes or when Epley partially effective

•First-line (horizontal canal): Gufoni manoeuvre or log roll (barbecue roll) - patient rolled 360° supine toward unaffected ear in 90° increments

🥈 Second-line

•vestibular rehabilitation (physiotherapy) for persistent imbalance or partial response

•Short-course prochlorperazine or cinnarizine - for acute severe nausea only; do NOT treat underlying cause

🥉 Third-line

•surgical posterior semicircular canal occlusion - truly refractory cases only; small risk of sensorineural hearing loss

⚠️

Vestibular sedatives (prochlorperazine, cinnarizine) are commonly overprescribed in BPPV. They suppress vestibular compensation and may prolong symptoms - repositioning manoeuvres are the treatment.

Prognosis and Follow-up

•Excellent prognosis - spontaneous resolution occurs within weeks to months even without treatment

•~80% achieve full resolution after a single Epley manoeuvre

•Recurrence in ~15-20% within 12 months; cumulative recurrence approaches 50% at 5 years

•Mild imbalance may persist 24-48 hours post-manoeuvre - reassure patient

•Vitamin D supplementation may reduce recurrence in deficient patients