Benign Paroxysmal Positional Vertigo (BPPV)

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Topic Overview

What is benign paroxysmal positional vertigo (BPPV)?

Vertigo is the feeling that you are spinning or the world is spinning around you. Benign paroxysmal positional vertigo is caused by a problem in the inner ear. It usually causes brief vertigo spells that come and go.

For some people, BPPV goes away by itself in a few weeks. But it can come back again.

BPPV is not a sign of a serious health problem.

What causes BPPV?

Benign paroxysmal positional vertigo (BPPV) is caused by a problem in the inner ear. Tiny calcium "stones" inside your inner ear canals help you keep your balance. Normally, when you move a certain way, such as when you stand up or turn your head, these stones move around. Sometimes these stones move into an area of your inner ear called the semicircular canal. When you move your head in certain ways, the stones in the semicircular canal move. Sensors in the semicircular canal are triggered by the stones, which causes a feeling of dizziness.

What are the symptoms?

The main symptom is a feeling that you are spinning or tilting when you are not. This can happen when you move your head in a certain way, like rolling over in bed, turning your head quickly, bending over, or tipping your head back.

BPPV usually lasts a minute or two. It can be mild, or it can be bad enough to make you feel sick to your stomach and vomit. You may even find it hard to stand or walk without losing your balance.

How is BPPV diagnosed?

Your doctor can usually tell that you have BPPV by asking you questions about your vertigo and doing a physical exam. You may have a test where your doctor watches your eyes while turning your head and helping you lie back. This is called the Dix-Hallpike test.

There are other things that can cause vertigo, so if your doctor doesn't think you have BPPV, you may have other tests too.

How is it treated?

Your doctor can usually do one of two procedures in the office that works for most cases of BPPV. These procedures are called the Epley maneuver and the Semont maneuver. If you don't want treatment or if treatment doesn't work, BPPV usually goes away by itself within a few weeks. Over time, your brain will likely get used to the confusing signals it gets from your inner ear. Either way, you can do some simple exercises that train your brain to get used to the confusing vertigo signals.

Medicine may help with severe nausea and vomiting.

Be extra careful so that you don't hurt yourself or someone else if you have a sudden attack of vertigo.

  • Do not drive or cycle if there is any chance that vertigo could strike and make you lose control. (This depends on what kind of movement triggers vertigo for you.)
  • At home, keep floors and walkways free of clutter so you don't trip.
  • Avoid heights.
  • Don't use tools or machines that could be dangerous if you suddenly get dizzy or lose your balance.

Frequently Asked Questions

Learning about benign paroxysmal positional vertigo (BPPV):

Being diagnosed:

Getting treatment:

Ongoing concerns:

Living with BPPV:

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Cause

Benign paroxysmal positional vertigo (BPPV) is caused by a problem in the inner ear. Tiny calcium "stones" inside your inner ear canals help you keep your balance. Normally, when you move a certain way, such as when you stand up or turn your head, these stones move around. Sometimes these stones move into an area of your inner ear called the semicircular canal. When you move your head in certain ways, the stones in the semicircular canal move. Sensors in the semicircular canal are triggered by the stones, which causes a feeling of dizziness.

Symptoms

The main symptom of benign paroxysmal positional vertigo (BPPV) is the feeling that you or your surroundings are spinning, whirling, or tilting. This sensation is called vertigo.

It is important to understand the difference between vertigo and dizziness. People often use those two terms as if they meant the same thing. But they are different symptoms, and they may point to different problems.

  • Vertigo is the feeling that you are spinning or the world is spinning around you. It happens when your body's balance sensory systems disagree about what kind of movement they sense. You may find it hard to walk or stand. You may even lose your balance and fall. If your vertigo is bad enough, you may also have nausea and vomiting.
  • Dizziness is not a feeling that you are spinning. It is a woozy or unsteady feeling.

To find out whether your vertigo is caused by BPPV, your doctor will want to find out what causes it, how bad it is, and how long it lasts. With BPPV:

  • Tilting the head, looking up or down, rolling over in bed, or getting in and out of bed causes vertigo.
  • It begins a few seconds after you move your head.
  • It usually lasts less than a minute. The spinning sensation may be mild, or it may be bad enough to cause nausea and vomiting.
  • Vertigo becomes less noticeable each time you repeat the same movement. After 3 or 4 repeats, the movement may no longer cause vertigo. Several hours may pass before the same movement again causes vertigo.

What Happens

Benign paroxysmal positional vertigo (BPPV) causes a whirling, spinning sensation even though you are not moving. If the vertigo is bad, it may also cause nausea or vomiting. The vertigo attacks happen when you move your head in a certain way, such as tilting it back or up or down, or by rolling over in bed. It usually lasts less than a minute. Moving your head to the same position again may trigger another episode of vertigo.

BPPV often goes away without treatment. Until it does, or is successfully treated, it can repeatedly cause vertigo with a particular head movement. Sometimes it will stop for a period of months or years and then suddenly come back.

What Increases Your Risk

Scientists think you're more likely to develop benign paroxysmal positional vertigo (BPPV) if you have one of these conditions:

  • You are an older adult.
  • You have a head injury.
  • You have an inflammation of the inner ear or of the nerve that connects the inner ear to the brain, a condition called vestibular neuritis.
  • You have ear surgery.

If you've had one episode of vertigo caused by BPPV, you are likely to have more.

When To Call a Doctor

Call 911 or other emergency services immediately if you have vertigo (a spinning sensation) and:

  • You passed out (lost consciousness).
  • You have symptoms of a stroke, such as:
    • Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.
    • Sudden vision changes.
    • Sudden trouble speaking.
    • Sudden confusion or trouble understanding simple statements.
    • Sudden problems with walking or balance.
    • A sudden, severe headache that is different from past headaches.
  • You have chest pain.
  • You have a headache, especially if you also have a stiff neck and fever.
  • You have sudden hearing loss.
  • You have numbness or tingling that does not go away, anywhere on your body.
  • You have vomiting that doesn't stop.
  • You had a recent head injury.

Call your doctor now or seek immediate care if:

  • You have an attack of vertigo that is different from those you have had before or from what your doctor told you to expect.
  • You need medicine to control nausea and vomiting caused by severe vertigo.

Call your doctor to schedule an appointment if:

  • This is the first time you have had an attack of vertigo.
  • You have a low-pitched roaring, ringing, or hissing sound in your ear, especially if you have not had this before. This is called tinnitus.
  • You have frequent or severe episodes of vertigo that interfere with your activities.

Watchful waiting

If your symptoms suggest benign paroxysmal positional vertigo (BPPV), watchful waiting may be appropriate. Over time BPPV may go away on its own. But treatment with a simple procedure in your doctor's office (either the Epley or Semont maneuver) can usually stop your vertigo right away. Talk to your doctor. If your vertigo interferes with your normal daily activities or causes nausea and vomiting, you may need treatment.

Who to see

The following health professionals are able to diagnose and treat BPPV and the causes of vertigo:

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Benign paroxysmal positional vertigo (BPPV) is diagnosed with a physical exam and your medical history. But diagnosing the cause of the spinning, whirling sensation of vertigo can be difficult. Several diseases, the side effects of medicines, and head injuries can also cause vertigo.

A Dix-Hallpike test may be done to help your doctor find out the cause of your vertigo. During this test, he or she will carefully observe any involuntary eye movements. This will help your doctor know whether the cause of your vertigo is inside your brain, your inner ear, or the nerve connected to your inner ear. The Dix-Hallpike test also can help your doctor find out which ear is affected.

If your symptoms or the results of your exam make your doctor think you don't have BPPV, other tests may be done:

  • Electronystagmography, which attaches small wires to your face that measure eye movements. It looks for the special eye movements that happen when the inner ear is stimulated. The pattern of eye movements can point to the location of the cause of the vertigo, such as the inner ear or the central nervous system.
  • Imaging tests, such as magnetic resonance imaging of the head (MRI) or computed tomography of the head (CT scan). These tests may be done if the symptoms and exam findings could be caused by a brain problem.
  • Hearing testing to detect hearing loss. A special hearing test can determine whether the nerve from the inner ear to the brain is working correctly. Hearing loss with vertigo usually points to a problem other than BPPV, such as Ménière's disease or labyrinthitis.

Treatment Overview

Benign paroxysmal positional vertigo (BPPV) may go away in a few weeks by itself. If treatment is needed, it usually consists of head exercises (Epley and Semont maneuvers). These exercises will move the particles out of the semicircular canals of your inner ear to a place where they will not cause vertigo.

Over time, your brain may react less and less to the confusing signals triggered by the particles in the inner ear. This is called compensation. Compensation occurs most quickly if you continue normal head movements, even though doing so causes the whirling sensation of vertigo. A Brandt-Daroff exercise may also be done to speed the compensation process.

Medicines called vestibular suppressants (such as antihistamines, sedatives, or scopolamine) may be tried if your symptoms are severe.

Antiemetic medicines may also be used to reduce nausea and vomiting that can occur with vertigo.

In rare cases, surgery may be used to treat BPPV.

Prevention

In most cases, benign paroxysmal positional vertigo (BPPV) cannot be prevented. But some cases may result from head injuries. Wearing a helmet when bicycling, motorcycling, playing baseball, or doing other sports activities can protect you from a head injury and BPPV.

Home Treatment

You can reduce the whirling or spinning sensation of vertigo when you have benign paroxysmal positional vertigo (BPPV) by taking these steps:

  • Use two or more pillows at night.
  • Avoid sleeping on your side with the ear that's causing the problem facing down.
  • Get up slowly in the morning and sit on the edge of the bed for a moment before standing.
  • Avoid leaning over to pick things up or tipping your head far back to look up.
  • Be careful about reclining, such as when you are in the dentist's chair or having your hair washed at a hair salon.
  • Be careful about playing sports that require you to turn your head, lean over, or lie flat on your back.

You can also help yourself by doing balance exercises and taking safety precautions.

  • Brandt-Daroff exercises can be done at home to help your brain get used to the abnormal balance signals triggered by the particles in the inner ear.
  • Balance exercises for vertigo, such as standing with your feet together, arms down, and slowly moving your head from side to side, may help you keep your balance and improve symptoms of vertigo.
  • Stay safe when you have balance problems by adding grab bars near the bathtub and toilet and keeping walking paths clear. This may prevent accidents and injuries.

Staying as active as possible usually helps the brain adjust more quickly. But that can be hard to do when moving is what causes your vertigo. Bed rest may help, but it usually increases the time it takes for the brain to adjust.

Medications

Medicines do not cure benign paroxysmal positional vertigo (BPPV). But they may be used to control severe symptoms, such as the whirling, spinning sensation of vertigo and the nausea and vomiting that may occur.

Medicine choices

Medicines to reduce the whirling sensation of vertigo are called vestibular suppressants. They include:

  • Antihistamines, such as meclizine (Antivert).
  • Scopolamine (Transderm-Scop).
  • Sedatives, such as clonazepam (Klonopin).

Antiemetic medicines, such as promethazine (Promethegan), may be used if you have severe nausea or vomiting.

What to think about

Medicines that calm the inner ear (vestibular suppressants) may also slow down the brain's ability to adjust to the abnormal balance signals triggered by the particles in the inner ear. They should be taken only to control severe symptoms.

Surgery

Ear surgery is an option for treating benign paroxysmal positional vertigo (BPPV) only in severe cases when other treatments have not worked.

Other Treatment

Exercises are used to treat benign paroxysmal positional vertigo (BPPV). These exercises help the particles in the semicircular canals of your inner ear move around, so that they don't cause vertigo. Although the exercises usually stop the vertigo for months or years, the problem may return and cause your symptoms to come back.

Other treatment choices

Exercises that may be used to treat BPPV include:

  • Epley maneuver and Semont maneuver. These exercises often cure BPPV by moving the particles in your inner ear so that they do not affect your balance. During these exercises, your doctor will help you hold your head in a series of positions. Often, one treatment is enough. You may be taught to do these exercises on your own at home.
  • Brandt-Daroff exercise. This exercise may be tried if the Epley or Semont maneuvers do not work. During this exercise, you will repeatedly go from a sitting position to a lying position until the vertigo stops. This exercise may help speed your brain's ability to adjust to the conflicting balance signals it is getting. You need to do these exercises several times a day for weeks for them to work.

What to think about

These exercises can get rid of BPPV symptoms. The Epley and Semont maneuvers usually are more comfortable than the Brandt-Daroff exercise, and they work faster-in one or two treatments rather than being repeated several times a day for weeks. So these maneuvers have become the first line of treatment.footnote 1

Other Places To Get Help

Organizations

American Hearing Research Foundation
www.american-hearing.org
National Institute on Deafness and Other Communication Disorders (U.S.)
www.nidcd.nih.gov

References

Citations

  1. Fife TD, et al. (2008). Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70(22): 2067-2074.

Other Works Consulted

  • Bhattacharyya N, et al. (2017). Clinical practice guideline: Benign paroxysmal positional vertigo (BPPV). Otolaryngology-Head and Neck Surgery, 156(3S): S1-S47. DOI: 10.1177/0194599816689667. Accessed March 2, 2017.
  • Hillier SL, McDonnell M (2011). Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews (2).
  • Hilton M, Pinder D (2004). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews (2). Oxford: Update Software.
  • Johnson J, Lalwani AK (2012). Vestibular disorders. In AK Lalwani, ed., Current Diagnosis and Treatment in Otolaryngology-Head and Neck Surgery, 3rd ed., pp. 729-738. New York: McGraw-Hill.
  • Kerber KA (2011). Episodic vertigo. In ET Bope et al., eds., Conn's Current Therapy 2011, pp. 210-213. Philadelphia: Saunders.
  • Von Brevern M, et al. (2006). Short-term efficacy of Epley's manoeuvre: A double-blind randomised trial. Journal of Neurology, Neurosurgery, and Psychiatry, 77(8): 980-982.
  • Walker MF, Daroff RB (2015). Dizziness and vertigo. In DL Kasper et al., eds., Harrison's Principles of Internal Medicine, 19th ed., vol. 1, pp. 148-151. New York: McGraw-Hill Education.

Credits

ByHealthwise Staff

Primary Medical ReviewerAnne C. Poinier, MD - Internal Medicine

Kathleen Romito, MD - Family Medicine

Specialist Medical ReviewerE. Gregory Thompson, MD - Internal Medicine

Current as ofMay 4, 2017

Current as of: May 4, 2017

Author: Healthwise Staff

Medical Review: Anne C. Poinier, MD - Internal Medicine & Kathleen Romito, MD - Family Medicine & E. Gregory Thompson, MD - Internal Medicine