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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.
What is benign paroxysmal positional vertigo (BPPV)?
Benign paroxysmal positional vertigo (BPPV) is a
common inner
ear disorder. With BPPV, changes in your head
position — such as tipping your head backward or
sitting up in bed — lead to sudden vertigo (a
feeling that the room is spinning).
BPPV isn’t a sign of a serious problem, and it
usually disappears on its own within a few days of
the first episode. (It could take several weeks for
some people.) However, the symptoms of BPPV can be
very frightening and may be dangerous, especially in
adults over the age of 65. The unsteadiness of BPPV
can lead to falls, which are a leading cause of fractures.
Who does benign paroxysmal positional vertigo
affect?
BPPV can affect people of all ages, but it’s most
common in adults over the age of 50. About half of
all people in this age range experience at least one
episode of BPPV in their lifetime.
BPPV can affect children, but it’s rare.
How common is BPPV?
Benign paroxysmal positional vertigo is the most
common inner ear disorder. In fact, approximately
20% of people who are evaluated for dizziness are
diagnosed with BPPV.
Is BPPV permanent?
BPPV usually goes away on its own. However, until
it’s successfully treated, it can come back. In some
cases, months — or even years — go by before another
episode occurs.
Symptoms and Causes
What are the symptoms of benign paroxysmal
positional vertigo?
Vertigo is the main symptom of BPPV. This vertigo
sensation can range from mild to severe and may last
seconds, or up to 1 minute.
It may be accompanied by
other benign paroxysmal positional vertigo symptoms,
including:
- Dizziness.
- Lightheadedness.
- Balance problems.
- Nausea and vomiting.
- Blurred vision.
- Nystagmus (rapid, involuntary eye
movements). During a vertigo episode, patients
with BPPV often exhibit nystagmus. This is involuntary
eye movement. These movements are usually rotary or
upbeat. They can help healthcare providers diagnose the
affected ear and the specific semicircular canal
involved.
While BPPV usually only affects one ear at a time,
it can potentially affect both ears.
What triggers BPPV?
BPPV
is almost always triggered by a change in your head’s
position.
Vertigo episodes in BPPV are usually triggered by specific
head movements. For example:
Triggering Movement |
Description |
Rolling over in bed |
Turning the head to one side while lying down |
Looking up or down |
Tilting the head back or forward |
Bending over |
Lowering the head, such as to pick something up |
Getting in or out of bed |
Transitions between lying down and sitting up |
In some instances, BPPV may be a symptom of another
inner ear condition, such as:
- Labyrinthitis.
- Vestibular neuritis.
- Acoustic neuroma.
Additionally, BPPV may accompany migraines,
or it may develop after a traumatic event — such as
a fall, accident or sports injury.
Causes
The exact cause of BPPV is not always known. There are two
main theories: canalithiasis and cupulolithiasis. Both
involve tiny calcium carbonate crystals, called otoconia,
moving in the inner ear.
Canalithiasis
Canalithiasis is the most common reason for BPPV. It happens
when otoconia move from the utricle to a semicircular canal,
often the posterior one. When the head moves, the otoconia
cause the cupula to send false signals to the brain, leading
to vertigo.
Cupulolithiasis
Cupulolithiasis is less common than canalithiasis. Here,
otoconia stick to the cupula, the sensory part of the
semicircular canal. This makes the cupula send false signals
to the brain when the head moves, causing vertigo.
What brings on BPPV?
In many people, especially older adults, there is no
specific event that causes BPPV to occur, but there are some
things that may bring on an attack:
-
Head trauma: A big hit to the head can knock otoconia loose, causing BPPV.
-
Age: Older adults, over 50, are more likely to get BPPV because of natural
changes in the otoconia.
-
Osteoporosis: This condition can make otoconia more likely to move.
-
Migraine: People with migraines are more likely to get BPPV, but why is not
fully understood.
-
Other things, like long bed rest, inner ear problems, and some medicines, can
also lead to BPPV. Knowing these causes and risk factors helps in preventing and
managing this common disorder.
Diagnosis and Tests
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.
Management and Treatment
There are several effective ways to manage benign
paroxysmal positional vertigo (BPPV). The main goal is
to ease symptoms and improve life quality. Common treatments
include canalith
repositioning maneuvers, vestibular
rehabilitation therapy, and medications.
Canalith repositioning maneuvers, like the Epley
maneuver, help move otoconia crystals back to the
utricle. A healthcare professional guides these head and
body movements. The choice of maneuver depends on the
affected canal and BPPV type.
Vestibular rehabilitation therapy is key in BPPV
treatment. It involves exercises to adapt to vestibular
system changes. Patients learn head and eye movements to
improve balance and reduce dizziness. This therapy is often
paired with canalith
repositioning maneuvers for best results.
Canalith Repositioning Maneuvers
Canalith repositioning maneuvers are a top choice for
treating BPPV. They aim to move the otolith crystals back to
the utricle. This helps get rid of vertigo and dizziness
caused by BPPV.
Epley Maneuver
The Epley
maneuver is a key method for BPPV in the posterior
semicircular canal. It involves head movements to move the
crystals back to the utricle. A healthcare pro does this,
but you can also learn it at home.
Semont Maneuver
The Semont
maneuver is great for BPPV in the posterior semicircular
canal. It involves quick side-to-side movements with the
head up. This helps move the crystals back to the utricle.
Foster Maneuver
The Foster
maneuver, or half somersault, is a home treatment for
BPPV in the posterior semicircular canal. It’s done by
following specific head and body movements. It’s an option
instead of the Epley and Semont maneuvers.
Here are the success rates of these maneuvers:
Maneuver |
Success Rate |
Epley |
80-90% |
Semont |
75-85% |
Foster |
70-80% |
Some patients might need more than one session to fully get
rid of BPPV symptoms. Always talk to a healthcare pro before
trying these at home. They can guide you and make sure
you’re doing it right.
Vestibular Rehabilitation Therapy
Vestibular rehabilitation therapy is a special kind of
physical therapy. It helps people with BPPV get better at
balancing and feeling stable. This therapy includes three
main types of exercises: balance, gaze stabilization, and
habituation.
Balance exercises help you stay steady and avoid falls.
You might stand on different surfaces, walk heel-to-toe, or
do single-leg stands. These exercises help your brain learn
to keep you stable again.
Gaze stabilization exercises improve how your eyes and
brain work together. They reduce vertigo and dizziness from
BPPV. You’ll focus on a fixed object while moving your head
or track a moving object with your eyes.
Habituation exercises help you get used to things that
usually make your BPPV symptoms worse. By facing these
triggers in a safe way, you can make your symptoms less
severe. For example, the Brandt-Daroff exercises help your
brain adjust to position changes.
Your physical therapist will create a plan just for you.
They’ll consider your needs and how bad your symptoms are.
With regular practice and your therapist’s help, you can
manage your symptoms and live better.
What is the fastest way to cure BPPV?
The most effective benign paroxysmal positional
vertigo treatments involve physical therapy
exercises. The goal of these exercises is to move
the calcium carbonate particles out of your
semicircular canals and back into your utricle.
Here, the particles resorb more easily and don’t
cause uncomfortable symptoms.
You can also take motion
sickness medications to relieve your symptoms.
However, you shouldn’t take these medications long
term.
Benign paroxysmal positional vertigo exercises: How
do they work?
Vertigo is often caused by the displacement of small calcium
carbonate crystals, or canaliths, within your inner ear. The
Epley maneuver, also known as the canalith repositioning
procedure (CRP) is a method to remove these crystals trapped
in your ear’s semicircular canal. typically take about
15 minutes to complete. Particle repositioning
involves a series of physical movements that change
the position of your head and body. These actions
shift the otoconia out of your semicircular canals
and back into their proper location in your utricle.
A single particle repositioning procedure is
effective in treating about 80% to 90% of cases of
BPPV. Additional BPPV exercises may be needed if
symptoms continue.
Your healthcare provider can perform this maneuver
during an office visit. They can also demonstrate
how to do these exercises at home to ease your BPPV
symptoms.
In the meantime, here are some step-by-step
instructions to try:
-
Step 1: Start by sitting up on a bed or
table. Turn your head 45 degrees toward the
affected ear.
-
Step 2: Quickly lie back, keeping your
head turned toward the affected ear as you lie
back with your head slightly over the edge of
the bed or table. Wait about a minute or until
you stop having symptoms.
-
Step 3: Without raising your head, turn
your head quickly in the opposite direction so
that your “good” ear is parallel with — but
slightly over the edge of — the table or bed.
Wait about a minute or until you stop having
symptoms.
-
Step 4: Roll onto your side. Continue
to turn your head another 90 degrees in the same
direction as step 3 so that your nose is now
facing the floor. Wait about a minute.
-
Step 5: Keeping your chin tucked in
toward your shoulder, sit up in the direction
your body is facing. Follow any post-particle
repositioning instructions given to you by your
healthcare provider.
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%.
What Are Benign Paroxysmal Positional
Vertigo (BPPV) Medications?
Several medications, including common motion
sickness remedies, may relieve symptoms of BPPV and may be
used for less severe episodes of vertigo or in addition to
the Epley maneuvers described above.
- meclizine (Antivert, Bonine, Dramamine II, D-Vert)
- diazepam (Valium)
- dimenhydrinate (Dramamine)
- promethazine (Phenergan)
- scopolamine (Isopto, Scopace)
If the cause of vertigo is thought to be due to a viral
infection, antiviral medications like acyclovir (Zovirax)
may be prescribed.
Steroids like prednisone may be useful if nerve inflammation
is a potential reason for vertigo.
Can BPPV go away on its own?
Yes. In many cases, BPPV goes away on its own
eventually. But it can come back. If it does, your
healthcare provider can tell you how to manage your
symptoms when they occur.
Lifestyle and home remedies
Coping with Benign Paroxysmal Positional Vertigo (BPPV) can
be tough. But, there are ways to manage your symptoms and
live better. By changing your daily routine and home, you
can lessen BPPV’s effects on your life.
Adapting daily activities
To cut down vertigo episodes, adjust your daily life. Move
slowly when changing positions, like getting out of bed.
Avoid quick head movements and bending or looking up. Use
extra pillows at night to keep your head up and prevent
vertigo.
Fall prevention strategies
Falls are a big worry for BPPV sufferers. To lower this
risk, make your home safer. Put handrails on stairs and in
bathrooms, remove tripping hazards, and brighten your home.
Use a cane or walker for extra support. These steps can help
you stay safe and independent.
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.
How can I reduce my risk for BPPV?
You can’t prevent BPPV, but you can manage it with
particle repositioning exercises. To reduce your
risk of trauma-related BPPV, be sure to wear a
helmet when biking, playing contact sports or
participating in other similar activities.
Prognosis
What can I expect if I have benign paroxysmal
positional vertigo?
The good news is that BPPV doesn’t indicate a
serious health problem. Even so, dealing with your
symptoms can be scary and frustrating. Your
healthcare provider can teach you how to do BPPV
exercises at home so you can manage your symptoms at
the first sign of trouble.
How long does BPPV last?
In most cases, a BPPV episode lasts 1 to 2 minutes.
Your symptoms may be mild, or they may be so severe
that you throw up. You might even lose your balance
when you try to stand or walk. Can Benign Paroxysmal Positional Vertigo (BPPV) Go Away on
Its Own?
BPPV usually resolves on its own quickly or within a few
weeks or months, even without any specific treatment.
- The
Epley maneuver may cure the problem immediately.
- Medications may help control the severity of symptoms
- Vertigo
may recur months or years later after an initial
incidence.
- BPPV is
rarely a problem that cannot be resolved. Neurologists,
otolaryngologist, and vestibular rehabilitation physical
therapists may be of help in confirming the diagnosis
and resolving BPPV or controlling its symptoms.
When should I call the doctor?
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?
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.
Benign Paroxysmal Positional Vertigo (BPPV) Terms
-
Semicircular canals: These structures
act like a gyroscope, with canals positioned in
three dimensions: upward, downward, and
horizontal. Together, the canals send signals to
your brain about the rotation/positioning of
your head (for example, when you bend over or
spin around.)
-
Cupula: Detects the flow of fluid
within your semicircular canals. The flow of
fluid gives your body a sense of motion.
-
Utricle: An organ located in your inner
ear that helps control balance. Your utricle
contains hair cells, which are covered with
otoconia. The otoconia sway with gravity,
sending signals to your brain about the position
of your head and body (upright, tilted, etc.).
-
Otoconia: The tiny calcium crystal
particles that become dislodged from within your
utricle (where they can dissolve) and move into
your semicircular canals (where they can’t
dissolve).
-
Cochlea: The “snail-shell” sense organ
of your inner ear that translates sound into
nerve impulses that are sent to your brain.
FAQ's
Q: What is Benign Paroxysmal Positional Vertigo (BPPV)?
A: BPPV is a common disorder that causes brief dizziness. It
happens when tiny crystals in the inner ear move. This
movement can cause a spinning feeling when you move your
head.
Q: What are the symptoms of BPPV?
A: BPPV makes you feel dizzy when you move your head. This
can happen when you look up or roll over in bed. You might
also feel sick, vomit, or have trouble balancing.
Q: How is BPPV diagnosed?
A: Doctors use special tests to find BPPV. These tests move
your head in certain ways. They look for signs of dizziness
and eye movements. This helps rule out other problems. Q: What causes BPPV?
A: BPPV is caused by crystals moving in the inner ear. This
can happen from a head injury, getting older, or other ear
issues. There are two main reasons for this movement.
Q: What are the treatment options for BPPV?
A: Treatments for BPPV include special head movements and
therapy. These help move the crystals back to where they
belong. Therapy also helps you get used to the symptoms and
balance better.
Q: Can BPPV resolve on its own?
A: Sometimes, BPPV goes away by itself. But, it’s important
to see a doctor. They can help figure out what’s wrong and
treat it to make you feel better.
Q: How can I manage BPPV in daily life?
A: To deal with BPPV, you might need to change how you do
things. You could make your home safer, use special tools,
or learn how to prevent falls. Your doctor can help you find
ways to live better with BPPV.
One Final Note..
Benign paroxysmal positional vertigo isn’t life-threatening,
but it can have a significant negative impact on your
quality of life. If you’ve experienced sudden episodes of
dizziness, vertigo, balance problems or other symptoms
related to BPPV, call your healthcare provider. In most
cases, physical therapy exercises and home treatments can
keep your symptoms at bay. The lifetime prevalence of BPPV is about 2.4% and other
estimates range from 10-64 per 100,000 people in the general
population. However, many physicians think that the true
frequency may be higher. BPPV most often affects older
adults with a peak age of onset in the sixth decade. The
disorder may affect individuals of any age but is quite
uncommon in those under 20 years of age. Females are thought
to be affected at least twice as often as males.
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