Introduction

Benign paroxysmal positional vertigo (BPPV) is a fairly common condition where changes in head movements trigger short bursts of vertigo (a type of dizziness). Up to 50% of people will suffer with BPPV in their lifetime,¹ and its symptoms can have a debilitating impact on day to day life. The good news is that most cases of BPPV respond well to canal repositioning manoeuvres, such as the Epley manoeuvre, which can be performed by your GP. If you think you may be suffering from BPPV, please talk to your GP before attempting any of the manoeuvres mentioned. 

What is BPPV?

BPPV is a fairly common condition where changes in head movements trigger short bursts of vertigo (dizziness). It’s name, BPPV, describes the characteristics of the condition: 

• Benign: although it has a huge day to day impact on sufferers, it is not a serious condition 
• Paroxysmal: it characteristically occurs for intermittent short bursts of less than one minute 
• Positional: it is usually triggered by changes in head position 
• Vertigo: this is a type of dizziness where everything around you is spinning

What are the symptoms of BPPV?

If you’ve ever suffered from BPPV, you will know that it has a huge impact on day-to-day life. The symptoms include:

• Vertigo - usually feels like the world is spinning around you
• Triggered by head movements - such as sitting up from lying, turning over in bed, looking up or bending down
• Duration of vertigo is short - usually around 30 seconds to one minute
• Nystagmus - this is involuntary movements of the eyes that often occurs with vertigo

Causes and risk factors

BPPV occurs when microscopic calcium crystals move into the wrong part of the inner ear. These crystals are normally embedded in ‘jelly’ in parts of the inner ear called the utricle and saccule. Their role is to send messages to the brain to maintain balance during movement. However,  in BPPV, these crystals become loose and move into a different part of the inner ear, called the semicircular canal. When you move your head, these crystals then move too. This sends confusing signals to the brain, which then creates this sense of vertigo. 

What causes these crystals to become loose is mostly unknown, although some links have been made with trauma to the head, extended periods lying down, and other inner ear issues. It is also more likely to occur in older populations and women.² Some links have also been made between BPPV and high blood pressure, diabetes, osteoporosis and vitamin D deficiency.³

How is BPPV diagnosed?

To diagnose BPPV, your doctor will take your medical history and ask you questions about your dizziness. The Dix-hall Pike Manoeuvre can then be used to confirm whether BPPV is present. To carry out this test, your doctor will quickly move you from a sitting to lying down position, with your head turned 45 degrees to the right. Once lying down, your doctor will ask you if you are feeling dizzy, and check for any nystagmus. The dizziness and nystagmus should then settle in 30 seconds to a minute. If there is no nystagmus, the test can then be repeated on the left side. 

Whilst the Dix-Hallpike test is considered the gold standard test for diagnosing BPPV, studies estimate it is only between 48-88% accurate at detecting the condition.⁴ A negative test does also not rule out BPPV as it only shows that there is no active movement of crystals in the canal when it is performed.³

Sometimes the crystals can enter the lateral canal, in which case a slightly different test, called the head-roll manoeuvre, may be performed.⁴ The doctor will bend your head to 30 degrees, then roll you onto your side from your back, and watch for any nystagmus. 

Due to the wide array of causes of dizziness, it is possible your doctor may refer you for other tests to rule out other possible causes of your symptoms. 

What are the treatments for BPPV?

Sometimes BPPV will resolve spontaneously by itself. If this doesn’t happen, the main treatment consists of canal repositioning manoeuvres, which aim to move the crystals out of the canal.  

Epley manoeuvre

The Epley Manoeuvre is considered one of the main manoeuvres for the treatment of BPPV. Your doctor will take your head through a number of different positions, designed to move the loose crystals out of the canal. Between each position they will wait for your symptoms to subside. The Epley manoeuvre consists of:

• Turning your head 45 degrees towards the side that is triggering the vertigo
• Your doctor will then rapidly lie you back on the examination table and extend your head off the edge. This may trigger your symptoms
• They will then turn your head to the opposite side
• You will then be asked to turn so you’re lying more on your side, inline with your head
• You will then be helped to sit back upright

Many people feel an almost immediate improvement in their symptoms. However, after having the Epley manoeuvre done, you may feel dizzy and unwell for 24-48 hours after the treatment but this will ease. 

Research shows the Epley’s manoeuvre is a safe and effective procedure; however there is a high recurrence rate of BPPV after treatment of 36%.⁵ The Epley’s manoeuvre can be performed again at future episodes of BPPV. 

Semont manoeuvre

The Semont manoeuvre is another canal repositioning manoeuvre, similar to Epley’s. Your doctor will help you move quickly from lying on one side to the other. The steps include:

• Sitting you on  the edge of a treatment table with your legs hanging over the side
• Your head will be turned about 45 degrees away from the side affected by BPPV
• Your doctor will then help you quickly move you to a lying down position on the affected side so you are looking at the ceiling. Stay in this position until the dizziness subsides
• Your doctor will then move you back to upright, then quickly onto your other side so you are looking at the floor
• Once the vertigo eases, you will be helped back up into the sitting position

Overall, the evidence suggests that the Epley's manoeuvre is more effective than the Sermont manoeuvre.⁶ It is also more commonly used in the UK. 

Brandt Daroff exercises 

Brandt Daroff exercises are a series of movements involving head tilts that can help to reduce the symptoms from BPPV. There is some disagreement over how they work; some evidence suggests the exercises help to relocate the crystals, similar to an Epley’s manoeuvre. Other evidence suggests they may help to habituate the body to repeated exposure to the dizziness.⁷ Studies show that Brandt Daroff exercises have a similar effectiveness to the Epley manoeuvre.⁸ The steps include:

• Sitting on the edge of the bed and turn your head 45 degrees to the left 
• Lying down on your right side - you will now be looking at the ceiling
• Staying there for 30 seconds or until the dizziness eases
• Sitting up again and turn your head back to the middle
• Turning your head 45 degrees to the right, then lie down on your left side
• Staying there for 30 seconds or until your dizziness eases
• Sitting back up again

This should be performed five times in total, then 3 times a day for two weeks. 

Medical and surgical treatment options

Most sufferers of BPPV will not need surgery for the condition. In fact, surgical treatment for BPPV has decreased dramatically over recent years due to the success of the canal repositioning techniques.⁹ For the very rare patients who do not respond to the manoeuvres, medical and surgery may be an option. The main procedure that is recommended is posterior canal plugging, which aims to block the semicircular canal and prevent stones from entering it. Whilst this does prevent recurrence of the condition, it can result in hearing loss. Other surgical procedures on the nerves have been tried in the past, but most have now been abandoned due to the poor success rate. 

FAQs

How can I stop my BPPV from coming back?

Although the treatment of BPPV is very successful, there is an increased chance of it coming back again in the future.⁵ Whilst there is no way to completely avoid a recurrence of the condition, there are some things that may help. We know that having high blood pressure and diabetes can increase your risk of developing BPPV; therefore helping to reduce these risk factors through exercise, weight loss and medication may help. There is also evidence that vitamin D supplementation in people who are low in vitamin D may help reduce frequency of BPPV episodes.¹⁰ Maintaining good neck range of motion may be beneficial, as repeated sufferers of BPPV can have reduced neck movements.¹¹

How do you fix BPPV?

Sometimes BPPV will resolve spontaneously by itself. If this doesn’t happen, the main treatment consists of canal repositioning manoeuvres, which aim to move the crystals out of the canal. The most common is the Epley manoeuvre, which your GP should be able to perform. 

What causes ear crystals to dislodge?

BPPV occurs when microscopic calcium crystals come loose and move into the wrong part of the inner ear. What causes these crystals to become loose is mostly unknown, although some links have been made with trauma to the head, lots of time lying down, and other inner ear issues. It is also more likely to occur in older populations and women.² Some links have also been made between BPPV and high blood pressure, diabetes, osteoporosis and vitamin D deficiency.³