Benign Positional Paroxysmal Vertigo (BPPV)

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Though not fully understood, BPPV is thought to arise due to the displacement of otoconia (small crystals of calcium carbinate) from the vestibule of the inner ear into the fluid-filled semicircular canals. The posterior canal is the most commonly affected site, but the superior and horizontal canals can be affected as well[1].

The peripheral vestibular labyrinth contains sensory receptors in the form of ciliated hairs in the three semicircular canals and in the ear’s otolithic organs. They respond to movement and relay signals via the eight cranial nerve. Visual perception such as gravity, position, and movements also receive signals from somatosensory receptors in the peripheral vestibules. With the displacement of the otoconia into the semicircular canals, these delicate feedback loops relay conflicting signals.[2]


Dizziness is the complaint in 5.6 million clinical visits in the United States per year, and between 17 and 42 percent of these patients are diagnosed with BPPV.[3]

Prevalence has been reported at 10.7 to 64 per 100,000 population. Lifetime prevalence is 2.4 percent.[3]

Characteristics/Clinical Presentation

Symptoms of BPPV include:[4]

  • vertigo
  • light headedness
  • loss of balance
  • nausea
  • vomiting
  • nystagmus with positional change of the head

Each episode of BPPV lasts no more than one minute.

Associated Co-morbidities[5]

  • Meniere's disease
  • Vertebral basilar insufficiency
  • Migraine
  • Multiple sclerosis


There are no medications that directly treat BPPV, medications can help in suppressing the symptoms.[6]

Drug treatments are not presently recommended for BPPV and bilateral vestibular paresis. 

  1. Prophylactic agents (L-channel calcium channel antagonists, tricyclic antidepressants, beta-blockers) are the mainstay of treatment for migraine-associated vertigo.
  2. In individuals with stroke or other structural lesions of the brainstem or cerebellum, an eclectic approach incorporating trials of vestibular suppressants and physical therapy is recommended.
  3. Psychogenic vertigo occurs in association with disorders such as panic disorder, anxiety disorder and agoraphobia. Benzodiazepines are the most useful agents here.
  4. Undetermined and ill-defined causes of vertigo make up a large remainder of diagnoses. An empirical approach to these patients incorporating trials of medications of general utility, such as benzodiazepines, as well as trials of medication withdrawal when appropriate, physical therapy and psychiatric consultation is suggested. [7]

Diagnostic Tests/Lab Tests/Lab Values

Dix-Hallpike test[3]
Dix-Hallpike Test
Dix-Hallpike Test
  1. To check for right side involvement, rotate the patient's head to the right 45 degrees while in the long sitting position (this aligns the right posterior semicircular canal with the sagittal plane of the body).
  2. The examiner grasp the patient's head and quickly moves the patient to the supine position with the neck slightly extended (ear down position).
  3. The examiner checks for nystagmus. If present, note the latency, duration, and direction (should not last more than 1 minute). 


Measures involuntary eye movements with the head placed in different positions or by stimulating the balance organs.

Magnetic resonance imaging (MRI)[4]

Uses a magnetic field and radio waves to create cross-sectional images of the body. Would most likely be used to rule out acoustic neuroma or other lesions.

Etiology / Causes

Though the cause can often be unknown, degeneration of vestibular system of the inner ear is often problematic in older adults. Under age 50, head injury is a common cause. Vestibular viruses and Meniere’s disease also play a role. BPPV can also be a result of surgery due to prolonged supine positioning and possible trauma to the inner ear.[8]

Systemic Involvement

Fortunately, BPPV has very little systemic involvement. In serve cases of vomitting caused my BPPV, one may be at risk of dehydration.[4]

Medical Management (current best evidence)

This includes Canalith repositioning procedures, conservative treatments, and Semont maneuvers all in mentioned in Physical Therapy Management below. These techniques work for 80% of patients.[9]

For the other 20%, the best recommended surgery options is posterior canal plugging.[9]

Physical Therapy Management (current best evidence)

Canalith Repositioning Procedure[3]
Canalith Repositioning Procedure
Canalith Repositioning Procedure
  1. Patient starts in long sitting with the head rotated 45 degrees to the affected side. 
  2. Patient next rapidly reclined to the supine position with the neck slightly extended. This position is held for 30 seconds, or until nystagmus and dizziness subside.
  3. The patient's head is rotated 90 degrees to the opposite side. This position is held for 20 seconds, or until nystagmus and dizziness subside.
  4. The patient's head is turn another 90 degrees, requiring the patient to go from the supine to side-lying position. This position is held for 20 seconds, or until dizziness and nystagmus subside.
  5. The patient is brought up to the short-sitting position.

May need to complete this maneuver 1 to 3 visits complete resolution of symptoms.

Habituation techniques[8]

  1. Avoid quick spins or movements that provoke vertigo.
  2. Sleep in a semi-recumbant position for the next two nights following the above technique. In most cases a recliner works well, or stacking pillows at the head of the bed. Avoid sleeping on the affected side.
  3. Try to keep the head upright during the day, avoid all supine activities.
  4. After a week of being conservative, start to place the head (in controlled environments) in vertigo provoking positions.

Brandt-Daroff exercises  [10]

  1. Begin by sitting upright on bed (position 1)
  2.  Lie down onto side. Take no more than 1-2 seconds to do this
  3. Keep head looking up at 45 degree angle. Imagine someone standing about six feet in front of you, and keep looking at the person's head at all times (position 2)
  4. Remain on this side for thirty seconds, or until dizziness subsides.
  5. Return to an upright position and wait for thirty seconds (position 3)
  6.  Now lie down onto the other side. Again, it should take one or two seconds to get into position
  7. Keep the head at a 45 degree angle (position 4)
  8. Stay down for another thirty seconds, or until vertigo subsides
  9. Return to an upright position and wait for another thirty seconds.
Semont maneuver (home treatment)[3]
Semont Manuever
  1. Patient begins sitting in the short sitting position. The head is rotated 45 degrees towards the unaffected ear.
  2. The patient rapidly moves to side lying to the affected side (at this point to face should be oriented towards the ceiling). This position should be held for 30 seconds.
  3. Without any head movement, the patient is to move to side lying on the opposite side of the body (the face should be oriented towards the bed at this point). Hold this position for 30 seconds.

According to Bhattacharyya et al in a 2008 Otolaryngology-Head and Neck Surgery Journal, the Semont maneuver is more effective than Brandt-Daroff exercises. 

Outcome Measures

Dizziness Handicap Inventory

Clinician Videos

[11] [12]

Differential Diagnosis

Otological disorders include:[3]

  • Meniere's disease
  • vestibular neuritis
  • labyrinthitis
  • superior canal dehiscence syndrome
  • posttraumatic vertigo

Neurological disorders include:[3]

  • migraine-associated dizziness
  • vertbrobasilar insufficiency
  • demyelinating diseases
  • CNS lesions

Other possible causes are:[3]


Case Reports/ Case Studies

Epidemiology of benign paroxysmal positional vertigo: a
population based study

Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review


Benign Paroxysmal Positional Vertigo (for the clinician and patient)

Clinical Practice Guideline: BPPV (for the clinician)

Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review from PT Journal May 2010

Recent Related Research (from Pubmed)


  1. Timothy C. Hain, MD, BENIGN PAROXYSMAL POSITIONAL VERTIGO, site: , Page last modified: February 3, 2013
  2. 2.0 2.1 Sonia Sandhaus, Stop the spinning: Diagnosing and managing vertigo. Nurse Practitioner. 2002 Aug 1;27(8): 11-23.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Bhattacharyya N, Baugh R, Orvidas L, Barrs D, Bronston L, Haidari J, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology--Head And Neck Surgery: Official Journal Of American Academy Of Otolaryngology-Head And Neck Surgery, 2008, Nov; 139(5 Suppl 4): S47-S81
  4. 4.0 4.1 4.2 4.3 Mayo Clinic: Benign Paroxysmal Positional Vertigo. (Accessed 19 March 2011).
  5. Herdman SJ. Treatment of benign paroxysmalfckLRpositional vertigo. Phys The 1990; 70:38l-388
  6. ENT Today. BPPV: State of the Art in Diagnosis And Treatment. (accessed 4 Apr 2011).
  7. Hain TC, Uddin M., Pharmacological treatment of vertigo.CNS Drugs. 2003;17(2):85-100.
  8. 8.0 8.1 American Hearing Research Foundation: Benign Paroxysmal Positional Vertigo (BPPV). (Accessed 19 March 2011).
  9. 9.0 9.1 University of Maryland Medical Center: Hearing and Balance Center. (Accessed 19 March 2011).
  10. Janet Odry Helminski, David Samuel Zee, Imke Janssen and Timothy Carl Hain, Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review, May 2010 vol. 90 no. 5 663-678
  11. Dix Hallpike. Available from Last accessed [4/26/2011].
  12. Canalith Repositioning. Available from Last accessed [4/26/2011].