Benign paroxysmal positional vertigo (BPPV)

Overview

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo — the sudden sensation that you're spinning or that the inside of your head is spinning.

BPPV causes brief episodes of mild to intense dizziness. It is usually triggered by specific changes in your head's position. This might occur when you tip your head up or down, when you lie down, or when you turn over or sit up in bed.

Although BPPV can be bothersome, it's rarely serious except when it increases the chance of falls. You can receive effective treatment for BPPV during a doctor's office visit.

Symptoms

The signs and symptoms of benign paroxysmal positional vertigo (BPPV) may include:

• Dizziness
• A sense that you or your surroundings are spinning or moving (vertigo)
• A loss of balance or unsteadiness
• Nausea
• Vomiting

The signs and symptoms of BPPV can come and go and commonly last less than one minute. Episodes of BPPV can disappear for some time and then recur.

Activities that bring about the signs and symptoms of BPPV can vary from person to person, but are almost always brought on by a change in head position. Some people also feel out of balance when standing or walking.

Abnormal rhythmic eye movements usually accompany the symptoms of benign paroxysmal positional vertigo.

When to see a doctor

Generally, see your doctor if you experience any recurrent, sudden, severe, or prolonged and unexplained dizziness or vertigo.

Seek emergency care

Although it's uncommon for dizziness to signal a serious illness, see your doctor immediately if you experience dizziness or vertigo along with any of the following:

• A new, different or severe headache
• A fever
• Double vision or loss of vision
• Hearing loss
• Trouble speaking
• Leg or arm weakness
• Loss of consciousness
• Falling or difficulty walking
• Numbness or tingling

The signs and symptoms listed above may signal a more serious problem.

Causes

Often, there's no known cause for BPPV. This is called idiopathic BPPV.

When there is a known cause, BPPV is often associated with a minor to severe blow to your head. Less common causes of BPPV include disorders that damage your inner ear or, rarely, damage that occurs during ear surgery or long periods positioned on your back, such as in a dentist chair. BPPV also has been associated with migraines.

The ear's role

Inside your ear is a tiny organ called the vestibular labyrinth. It includes three loop-shaped structures (semicircular canals) that contain fluid and fine, hairlike sensors that monitor your head's rotation.

Other structures (otolith organs) in your ear monitor your head's movements — up and down, right and left, back and forth — and your head's position related to gravity. These otolith organs contain crystals that make you sensitive to gravity.

For many reasons, these crystals can become dislodged. When they become dislodged, they can move into one of the semicircular canals — especially while you're lying down. This causes the semicircular canal to become sensitive to head position changes it would normally not respond to, which is what makes you feel dizzy.

Risk factors

Benign paroxysmal positional vertigo occurs most often in people age 50 and older, but can occur at any age. BPPV is also more common in women than in men. A head injury or any other disorder of the balance organs of your ear may make you more susceptible to BPPV.

Complications

Although BPPV is uncomfortable, it rarely causes complications. The dizziness of BPPV can make you unsteady, which may put you at greater risk of falling.

Diagnosis

Your doctor may do a series of tests to determine the cause of your dizziness. During a physical exam, your doctor will likely look for:

• Signs and symptoms of dizziness that are prompted by eye or head movements and then decrease in less than one minute
• Dizziness with specific eye movements that occur when you lie on your back with your head turned to one side and tipped slightly over the edge of the examination bed
• Involuntary movements of your eyes from side to side
• Inability to control your eye movements

If your doctor can't find the cause of your signs and symptoms, he or she may order additional testing, such as:

• Electronystagmography (ENG) or videonystagmography (VNG). The purpose of these tests is to detect abnormal eye movement. ENG (which uses electrodes) or VNG (which uses small cameras) can help determine if dizziness is due to inner ear disease by measuring involuntary eye movements while your head is placed in different positions or your balance organs are stimulated with water or air.
• Magnetic resonance imaging (MRI). This test uses a magnetic field and radio waves to create cross-sectional images of your head and body. Your doctor can use these images to identify and diagnose a range of conditions. MRI may be performed to rule out other possible causes of vertigo.

Treatment

Benign paroxysmal positional vertigo may go away on its own within a few weeks or months. But, to help relieve BPPV sooner, your doctor, audiologist or physical therapist may treat you with a series of movements known as the canalith repositioning procedure.

Canalith repositioning

Performed in your doctor's office, the canalith repositioning procedure consists of several simple and slow maneuvers for positioning your head. The goal is to move particles from the fluid-filled semicircular canals of your inner ear into a tiny baglike open area (vestibule) that houses one of the otolith organs in your ear, where these particles don't cause trouble and are more easily resorbed.

Each position is held for about 30 seconds after any symptoms or abnormal eye movements stop. This procedure usually works after one or two treatments.

Your doctor will likely teach you how to perform the procedure on yourself so that you can do it at home if needed.

Surgical alternative

In rare situations when the canalith repositioning procedure doesn't work, your doctor may recommend a surgical procedure. In this procedure, a bone plug is used to block the portion of your inner ear that's causing dizziness. The plug prevents the semicircular canal in your ear from being able to respond to particle movements or head movements in general. The success rate for canal plugging surgery is about 90%.

Lifestyle and home remedies

If you experience dizziness associated with BPPV, consider these tips:

• Be aware of the possibility of losing your balance, which can lead to falling and serious injury.
• Avoid movements, such as looking up, that bring on the symptoms.
• Sit down immediately when you feel dizzy.
• Use good lighting if you get up at night.
• Walk with a cane for stability if you're at risk of falling.
• Work closely with your doctor to manage your symptoms effectively.

BPPV may recur even after successful therapy. Although there's no cure, the condition can be managed with physical therapy and home treatments.

Preparing for an appointment

Make an appointment with your doctor if you have symptoms common to BPPV. After an initial examination, your doctor may refer you to an ear, nose and throat (ENT) specialist or a doctor who specializes in the brain and nervous system (neurologist).

Here's some information to help you get ready for your appointment.

What you can do

• Write down your symptoms, including when they started and how often they occur.
• Note any recent blows to your head, including even minor accidents or injuries.
• Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins and supplements you're taking.
• Write down questions to ask your doctor. Creating your list of questions can help you make the most of your time with your doctor.

Questions to ask the doctor at the initial appointment include:

• What are the possible causes of my symptoms or condition?
• What tests do you recommend?
• If these tests don't pinpoint the cause of my symptoms, what additional tests might I need?
• Do I need to follow any restrictions while waiting for a diagnosis?
• Should I see a specialist?

Questions to ask if you are referred to a specialist include:

• What treatments are most likely to help me feel better?
• How soon after beginning treatment should my symptoms start to improve?
• If the first treatment doesn't work, what will you recommend next?
• Am I a candidate for surgery? Why or why not?
• What self-care steps can help me manage this condition?
• Do I need to restrict my activities? For how long?
• Am I at risk of this problem recurring?
• I have these other health conditions. How can I manage these conditions together?
• What handouts or websites do you recommend for learning more about BPPV?

What to expect from your doctor

A doctor who sees you for symptoms common to BPPV may ask a number of questions, such as:

• What are your symptoms, and when did you first notice them?
• Do your symptoms come and go? How often?
• How long do your symptoms last?
• Does anything in particular seem to trigger your symptoms, such as certain types of movement or activity?
• Do your symptoms include vision problems?
• Do your symptoms include nausea or vomiting?
• Do your symptoms include headache?
• Have you lost any hearing?
• Are you being treated for any other medical conditions?