Introduction

Unknown to many, dizziness is a common symptom in many medical conditions. It is challenging to establish any one potential diagnosis based on dizziness alone. However, dizziness that occurs with sudden head movement may be an indication of paroxysmal positional vertigo (PPV).

PPV is also commonly called benign paroxysmal positional vertigo (BPPV). Vertigo is defined as feeling as though you are moving even though you are stationary - usually termed as ‘dizziness’. The ‘paroxysmal’ and ‘positional’ terms in PPV refer to the sudden onset of bursts (paroxysmal) of dizziness when moving your head (positional). In addition to the dizziness, there are other identifying symptoms of the condition.

Although people of any age could develop PPV, it is most commonly observed in people between the ages of 50 and 70. In cases where it occurs in someone under the age of 35, it is most likely caused as a result of a head injury. It is important to treat the condition as symptoms could contribute to severe lifestyle disruptions.¹ 

What is PPV?

PPV is caused by an abnormality in detecting fluid in the inner ear, which is why sudden head movements can lead to the sensation of movement when in a stationary position. There are two types of PPV: primary or idiopathic benign paroxysmal positional vertigo (which is the most common) and vertigo caused due to an underlying condition (secondary), such as head trauma, labyrinthitis, vestibular neuritis, Ménière disease or migraines.²

Symptoms

Vertigo 

As described in the introduction, vertigo is the foremost symptom of PPV; attacks are often short and frequently last a few seconds to five minutes. Furthermore, they come on suddenly with movement.³

Nystagmus 

Nystagmus is another primary symptom of PPV. Nystagmus is a repeated and rhythmic involuntary movement of the eye - in essence, it is when the eyes shake from side to side, up and down or in a circular motion. If you were to visit a healthcare professional to get tested, they may put special glasses on you known as ‘Frenzel goggles’. These will aid them in better visualising the eye movement and reaching a diagnosis.³

Less common symptoms 

There are also less common but equally important symptoms that can be associated with PPV. These include:

• Nausea and vomiting 
• Light-headedness and balance issues 
• Anxiety and fear 

If any of these are experienced, the most likely reason is directly due to the aforementioned inner ear fluid balance problem. The anxiety and fear that patients can experience likely derive from having had one or more attacks of dizziness before. The anticipation of knowing that another attack is coming can cause anxiety, as symptoms can be disruptive to one’s everyday life. For example, it can stop you from exercising or operating heavy machinery (e.g. driving a car).¹ 

What’s causing you to feel these symptoms? 

In addition to the symptoms that you feel, it might be helpful to keep track of the things that you do to trigger these symptoms. For instance, as mentioned above, symptoms may be brought about when changing the position of your head. This can happen when you turn over in bed, when you move your head to look upwards or downwards or even when you are bending over.³

When doctors are trying to diagnose PPV, they will conduct a test known as the Dix-Hallpike test. To start the manoeuvre, you will be asked to sit up with your legs straight out on the examination table. The physician will then place their hands on your head and turn it very slightly in the direction of the ear that is being tested. They will then very quickly lay you down with your head hanging from the edge of the table. They will then observe if the position your head remains in and whether there is also any evident nystagmus. You would need to be in this position for at least 30 seconds.⁴

Please note that if the doctor offers to perform the Dix-Hallpike manoeuvre on you, they will brief you fully on the procedure due to the nature of the test. They may also offer an antiemetic to help alleviate any nausea or vomiting that may follow from the test.⁴

How would a doctor diagnose you with PPV?

The two main things needed for benign paroxysmal positional vertigo to be diagnosed are the symptoms experienced by the patient and a positive Dix-Hallpike test. For PPV that is secondary to another underlying condition, more tests are often carried out. These are often in the form of clinical imaging and laboratory tests. 

Imaging that may be conducted includes an MRI or a CT scan of the head. These will help identify any internal bleeding, masses (either benign or cancerous) or any other internal pathology (e.g. inflammation in vestibular neuritis).⁵

Audiometry can also be used to assess levels of hearing loss that may occur with PPV.⁶

What can you do about it?

PPV in the form of benign paroxysmal positional vertigo is usually self-limiting and should typically resolve within 6 months. If this is not the case, then it is traditionally treated via non-surgical methods, usually in the form of further manoeuvres such as the Liberatory manoeuvre or the Epley manoeuvre. It is extremely important to know that with the Dix-Hallpike manoeuvre, it is essential that you are fully briefed on how these manoeuvres are done prior to assessment.²

Liberatory manoeuvre

For this manoeuvre, you begin by sitting on the examination table, head turned in the opposite direction to the ear that is being tested. You will then swiftly be positioned so that you are lying on your side (the side of the affected ear), and your head will be facing up.

After a period of about 5 minutes, you will quickly be positioned back into the sitting position and then you will be positioned so that you are lying sideways towards the unaffected ear with your head facing down. This manoeuvre is effective but difficult to carry out on more frail or elderly patients due to its nature.²

Epley manoeuvre

One of the most effective treatments is a simple procedure called the Epley manoeuvre. This is a series of head and body movements done to help move tiny calcium crystals in your inner ear back to where they belong. These crystals are what cause the spinning sensation or dizziness. The Epley manoeuvre is safe, quick, and often provides relief within just a few sessions. Many people feel much better afterward, sometimes even immediately. It’s a highly recommended and widely used method to manage BPPV without the need for medication or surgery.

For the Epley manoeuvre, you would start with your head held at an angle and hanging from the edge of the table as done in the Dix-Hallpike manoeuvre. The physician would then wait for any nystagmus to improve or completely subside. Your head will then be turned 90 degrees in the opposite direction and held there for about 30 seconds.

You will then be instructed to turn your entire body in that same direction while your head is turned so that you are facing the floor. To end the manoeuvre, the physician will then help you sit up.⁷ It is recommended that you keep your head upright for the next 1-2 days for the manoeuvre to be fully effective. 

Summary

In summary, PPV can be diagnosed in two types - benign positional paroxysmal vertigo (BPPV) or PPV secondary to an underlying condition. These present with vertigo (dizziness) and nystagmus. You could also experience less common symptoms such as nausea, vomiting, feeling light-headed, feeling unsteady on your feet, anxiety and fear. The two types can be differentiated via positional manoeuvres and other diagnostic tests, such as imaging. Early recognition and treatment can help ease an individuals associated anxiety. This can subsequently improve their overall quality of life. Treatment is usually nonsurgical and composed of manoeuvres such as the Liberatory or Epley manoeuvres.