BPPV Summary

Key Features:

Diagnosis:

Management:

Prognosis:

Red Flags: Consider central causes if atypical features (no latency, no fatigue, vertical nystagmus)

Benign Paroxysmal Positional Vertigo (BPPV)

Diagnosis and Management Guidelines

Benign paroxysmal positional vertigo (BPPV) is defined as a disorder of the inner ear characterised by repeated episodes of positional vertigo. It is thought to be caused by loose calcium carbonate debris (otoconia) in the semicircular canals of the inner ear (canalithiasis).

Key Features: Posterior semicircular canal most commonly affected (85-95% of cases). Most common cause of vertigo in clinical practice. Typically affects ages 50-70, more common in women.

Diagnosis

Clinical History

  • Vertigo triggered by head movements (lying down, turning in bed)
  • Episodes last <1 minute (often overestimated)
  • Nausea/vomiting may occur
  • No hearing loss or tinnitus
  • Asymptomatic between attacks

Examination Findings

  • Normal exam at rest
  • Dix-Hallpike positive for posterior canal BPPV:
    • Torsional upbeating nystagmus
    • Latency (5-20 sec)
    • Duration <1 minute
    • Fatigues with repetition

Caution: Avoid Dix-Hallpike in patients with neck/back problems or cardiovascular conditions like carotid sinus syncope.

Dix-Hallpike Manoeuvre

Step 1

Patient sits upright with head turned 45° to one side

Step 2

Rapidly lie patient down with head extended 20-30° over couch edge

Step 3

Maintain position for 30+ seconds observing for nystagmus

Step 4

Slowly return to sitting position

Step 5

Repeat on opposite side if first test negative

Patient Advice: Warn about transient vertigo during test. Keep eyes open looking straight ahead.

Management

Patient Education

  • Most recover within weeks (even without treatment)
  • Repositioning manoeuvres can accelerate recovery
  • Avoid sudden head movements/looking upwards
  • No driving during symptomatic periods

Treatment Options

  • Epley manoeuvre (first-line)
  • Brandt-Daroff exercises (home alternative)
  • Watchful waiting (acceptable option)
  • Follow-up in 4 weeks if unresolved

Note: Symptomatic drug treatment is not usually helpful for BPPV.

Epley Manoeuvre

Position 1

Start sitting with head turned 45° to affected side

Position 2

Lie back (head dependent 30°) for 30+ seconds

Position 3

Rotate head 90° to opposite side (face up)

Position 4

Roll onto side while rotating head nose-down 45°

Position 5

Sit up sideways with head rotated/tilted

Contraindications/Precautions

  • Neck/back problems
  • Unstable cardiac disease
  • Suspected vertebrobasilar disease
  • Carotid stenosis
  • Morbid obesity