Health Library Benign Paroxysmal Positional Vertigo (BPPV)From Healthwise

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?

Normally, there are little calcium “stones” in the inner ear canals that are moved around by gravity. BPPV can be caused by things like infection or inflammation that stop the stones from moving around like normal. This sends a false message to the brain that affects your balance.

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?

You and your doctor will talk about your symptoms. Your doctor will do a full physical exam and will test your nervous system to see if there’s a problem with how your nerves send messages to your brain. Your doctor may be able to tell that you have BPPV by watching how your eyes move as you turn your head and lie back. This is called the Dix-Hallpike test.

There are other things that can cause vertigo, so you may have other tests too.

How is it treated?

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. But you can do some simple exercises that might make the vertigo go away faster.

One kind of exercise for BPPV can move the calcium stones in a way that they don't trigger vertigo. Another kind of exercise can try to train your brain to get used to the confusing vertigo signals.

Medicine can help with severe vertigo that makes you sick to your stomach. But using this kind of medicine can also make BPPV take longer to go away. Only you know whether you feel sick enough that it is worth it to take medicine (and possibly have vertigo longer).

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 lose your balance.

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Experts believe benign paroxysmal positional vertigo (BPPV) is probably the result of a buildup of particles in the inner ear. This is probably what happens:

• Tiny calcium particles, called canaliths, move abnormally in the inner ear.
• When you move your head a certain way, such as tipping it back to look up, the particles float around in the canal, brushing against tiny hairs that detect movement. When this system is not working normally, the hairs mistakenly tell your brain that you are moving in a way that you are not.
• Because your other balance systems do not detect the same movement, they send conflicting signals to your brain, and vertigo is the result.

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 indicate 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 determine whether your vertigo is caused by BPPV, your health professional 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 to 4 repeats, the movement may no longer cause vertigo. Several hours may pass before the same movement again causes in vertigo.

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.

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.

Call your health professional immediately if you have the spinning, whirling sensation of vertigo together with any of the following:

• A head injury
• Complete, sudden hearing loss
• Weakness in an arm or leg
• Blurred or double vision
• Difficulty speaking
• Persistent numbness or tingling anywhere on your body

Call your health professional 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.
• You have an attack of vertigo that is different from what you were told to expect.
• You need medicine to control nausea and vomiting.

Watchful Waiting

If your symptoms suggest benign paroxysmal positional vertigo (BPPV), watchful waiting may be appropriate. BPPV may go away on its own in time. If it interferes with your normal daily activities or causes nausea and vomiting, treatment may be needed.

Who To See

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

• Family doctor
• General practitioner
• Physician assistant
• Nurse practitioner
• Internist
• Otolaryngologist
• Neurologist

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

Benign paroxysmal positional vertigo (BPPV) is diagnosed with a detailed physical and neurologic exam and from your medical history. However, 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 health professional determine the cause of your vertigo. During this test, he or she will carefully observe any involuntary eye movements. This will help determine 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 determine which ear is affected.

Other tests may be done to help diagnose your condition:

• 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 indicates a problem other than BPPV, such as Ménière's disease or labyrinthitis.

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

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. This exercise takes you from sitting to lying on the side that causes the worst vertigo. You'll remain in this position until either the vertigo goes away or until 30 seconds have passed. This movement is then repeated on the other side. These exercises are done twice a day for several weeks to months, or until the vertigo goes away.

Medicines called vestibular suppressants (such as antihistamines, sedatives, or scopolamine) reduce vertigo and may be tried if your symptoms are severe. However, using medications to control vertigo often extends the time needed for compensation to occur.

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

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

In most cases, benign paroxysmal positional vertigo (BPPV) cannot be prevented. However, 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.

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 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 participating in 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.

Taking safety precautions for vertigo, such as adding grab bars near the bathtub and toilet and keeping walking paths clear, may prevent accidents and injuries.

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 maintain your balance and improve symptoms of vertigo.

If your health professional treated you with a Semont or Epley maneuver, you may be instructed to restrict your head movement for about a day. Do this by sleeping with your head propped up, not sleeping on the affected side, and not tipping your head too far up or down.

If your health professional has you try the Brandt-Daroff exercise to help your brain adjust, you will need to do the exercises at home several times a day, possibly for weeks. The exercises will allow your brain to get used to the abnormal balance signals triggered by the particles in the inner ear.

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

Medication Choices

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

• Antihistamines, such as Dramamine (dimenhydrinate), Antivert (meclizine), Benadryl (diphenhydramine).
• Scopolamine, also known as Transderm-Scop.
• Sedatives, such as Valium (diazepam) or Klonopin (clonazepam).

Antiemetic medications may be used if you have nausea or vomiting along with the vertigo.

What To Think About

Medications 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 for 1 to 2 weeks to control severe symptoms.

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

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 affect your balance. 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:

• Semont maneuver and modified Epley 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 health professional 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 may be tried if the Semont or modified Epley 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 eliminate symptoms of BPPV, and they have about the same success rates. The Semont and modified Epley 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. Therefore, these maneuvers have become the first line of treatment.¹

Organizations

• Labyrinthitis
• Ménière's Disease
• Vestibular Neuritis

Citations

1. Koelliker P, et al. (2001). Benign paroxysmal positional vertigo: Diagnosis and treatment in the emergency department—A review of the literature and discussion of canalith-repositioning maneuvers. Annals of Emergency Medicine, 37(4): 392–398.

Other Works Consulted

• Solomon D, Frohman EM (2005). The dizzy patient. In DC Dale, DD Federman, eds., ACP Medicine, section 11, chap. 1. New York: WebMD.

• Von Brevern M, et al. (2004). Migrainous vertigo presenting as episodic positional vertigo. Neurology, 62(3): 469–472.

Author:	Kathe Gallagher, MSW	Last Updated: January 29, 2007
Medical Review:	Anne C. Poinier, MD - Internal Medicine Barrie J. Hurwitz, MD - Neurology
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