Benign Paroxysmal Positional Vertigo
Benign Paroxysmal Positional Vertigo
Benign Paroxysmal Positional Vertigo
Timothy C. Hain, MD Page last modified: May 12, 2011 Korean Version Spanish Version
Causes Diagnosis Treatment
In Benign Paroxysmal Positional Vertigo (BPPV) dizziness is generally thought to be due to debris which has
collected within a part of the inner ear. This debris can be thought of as "ear rocks", although the formal name is
"otoconia". Ear rocks are small crystals of calcium carbonate derived from a structure in the ear called the
"utricle" (figure1 ). While the saccule also contains otoconia, they are not able to migrate into the canal system.
The utricle may have been damaged by head injury, infection, or other disorder of the inner ear, or may have
degenerated because of advanced age. Normally otoconia appear to have a slow turnover. They are probably
dissolved naturally as well as actively reabsorbed by the "dark cells" of the labyrinth (Lim, 1973, 1984), which
are found adjacent to the utricle and the crista, although this idea is not accepted by all (see Zucca, 1998, and
Buckingham, 1999).
BPPV is a common cause of dizziness. About 20% of all
dizziness is due to BPPV. While BPPV can occur in children
(Uneri and Turkdogan, 2003), the older you are, the more
likely it is that your dizziness is due to BPPV. About 50% of
all dizziness in older people is due to BPPV. In one study, 9%
of a group of urban dwelling elders were found to have
undiagnosed BPPV (Oghalai et al., 2000).
The symptoms of BPPV include dizziness or vertigo,
lightheadedness, imbalance, and nausea. Activities which
bring on symptoms will vary among persons, but symptoms
are almost always precipitated by a change of position of the
head with respect to gravity. Getting out of bed or rolling over
in bed are common "problem" motions . Because people with
BPPV often feel dizzy and unsteady when they tip their heads
back to look up, sometimes BPPV is called "top shelf
vertigo." Women with BPPV may find that the use of shampoo bowls in beauty parlors brings on symptoms. A
Yoga posture called the "down dog", or Pilates are sometimes the trigger. An intermittent pattern is common.
BPPV may be present for a few weeks, then stop, then come back again.
Wait it out
Office Treatment
Home Treatment
Surgical Treatment
BPPV has often been described as "self-limiting" because symptoms often subside or disappear within 2 months
of onset (Imai et al, 2005). BPPV is not life-threatening. One can certainly opt to just wait it out.
get something out of a cabinet. Be careful when at the dentist's office, the beauty parlor when lying back having
ones hair washed, when participating in sports activities and when you are lying flat on your back.
Symptoms tend to wax and wane. Motion sickness medications are sometimes helpful in controlling the nausea
associated with BPPV but are otherwise rarely beneficial.
As BPPV can last for much longer than 2 months, in our opinion, it is better to treat it actively and be done with
it rather than taking the wait/see approach.
1. Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or
brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don't drive yourself home.
2. Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and
upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a
couch (see figure 3). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist.
No exercise which requires head movement. When men shave under their chins, they should bend their bodies
forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head
back. Shampoo only under the shower. Some authors suggest that no special sleeping positions are necessary
(Cohen, 2004; Massoud and Ireland, 1996). We, as do others, think
that there is some value (Cakir et al, 2006)
3. For at least one week, avoid provoking head positions that might
bring BPPV on again.
4. At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself
cautiously and under conditions in which you can't fall or hurt yourself. Let your doctor know how you did.
Variant maneuvers:
Comment: Massoud and Ireland (1996) stated that post-treatment instructions were not necessary. While we
respect these authors, at this writing (2002), we still feel it best to follow the procedure recommended by Epley.
While some authors advocate use of vibration in the Epley maneuver, we have not found this useful in a study of
our patients (Hain et al, 2000). Use of an antiemetic prior to the maneuver may be helpful if nausea is
anticipated.
Some authors suggest that position 'D' in the figure is not necessary (e.g. (Cohen et al. 1999; Cohen et al. 2004 ).
In our opinion, this is a mistake as mathematical modeling of BPPV suggests that position 'D' is the most
important position (Squires et al, 2004). Mathematical modeling also suggests that position 'C' is probably not
needed. In our opinion, position 'C' has utility as it gives patients a chance to regroup between position 'B' and
'D'.
The "Gans" maneuver. This is a little used treatment maneuver, called the "Gans maneuver by it's inventor (R.
Gans, Ph.D.), that is a hybrid between the Epley and Semont maneuvers. It incorporates the head orientations to
gravity of "B" and "D" in the Epley figure above, using the body positions of the Semont maneuver. It leaves out
position 'C' in the figure above. There is too little published experience with this maneuver to say whether it is as
effective as the Epley/Semont but we suspect that it has the same efficacy, as it uses the same head orientations
with respect to gravity.
Exercise
Duration
Morning
5 repetitions
10 minutes
Noon
5 repetitions
10 minutes
Evening
5 repetitions
10 minutes
Start sitting upright (position 1). Then move into the side-lying position (position 2), with the head angled
upward about halfway. An easy way to remember this is to imagine someone standing about 6 feet in front of
you, and just keep looking at their head at all times. Stay in the side-lying position for 30 seconds, or until the
dizziness subsides if this is longer, then go back to the sitting position (position 3). Stay there for 30 seconds, and
then go to the opposite side (position 4) and follow the same routine.
These exercises should be performed for two weeks, three times per day, or for three weeks, twice per day. This
adds up to 42 sets in total. In most persons, complete relief from symptoms is obtained after 30 sets, or about 10
days. In approximately 30 percent of patients, BPPV will recur within one year. Unfortunately, daily exercises
are not effective in preventing recurrence (Helminski and Hain, 2008). The Brandt-Daroff exercises as well as
the Semont and Epley maneuvers are compared in an article by Brandt (1994), listed in the reference section.
When performing the Brandt-Daroff maneuver, caution is advised should neurological symptoms (i.e. weakness,
numbness, visual changes other than vertigo) occur. Occasionally such symptoms are caused by compression of
the vertebral arteries (Sakaguchi et al, 2003). In this situation we advise not proceeding with the exercises and
consulting ones physician.
Multicanal BPPV (usually mild) often is a consequence of using the Brandt-Daroff exercises.
Don't do these
There are several surgical procedures that we feel are simply inadvisable for the individual with intractable
BPPV. Canal plugging is preferable to all of these. Vestibular nerve section, while effective, eliminates more of
the normal vestibular system than is necessary. Similarly, transtympanic gentamicin treatment is generally
inappropriate. Labyrinthectomy and sacculotomy are also both inappropriate because of reduction or loss of
hearing expected with these procedures.
ATYPICAL BPPV
debris is movable. Very little data is available as to the frequency of this pattern, and no data is available
regarding treatment.
Multicanal BPPV. If debris can get into one canal, why shouldn't it be able to get into more than one ? It is
common to find small amounts of horizontal nystagmus or contralateral downbeating nystagmus in a person with
classic posterior canal BPPV. While other explanations are possible, the most likely one is that there is debris in
multiple canals. Gradually a literature is developing about these situations (Bertholon et al, 2005).