Benign Paroxysmal Positional Vertigo

• Benign Paroxysmal Vertigo is a common inner ear disorder that causes brief episodes of vertigo (a false sense of spinning) or dizziness associated with head movement.
• It can occur just once or twice, or it can last days or weeks, or, rarely, for months.
• Benign Paroxysmal Vertigo is a specific diagnosis, and each word describes a condition:
  • Benign: not life-threatening, even though the symptoms can be very intense and upsetting.
  • Paroxysmal: comes in sudden, short spells.
  • Positional: Certain head positions or movements can trigger a spell.
  • Vertigo: feeling like you are spinning, or the world around you is spinning.
• Symptoms of Benign Paroxysmal Positional Vertigo include:
  • Vertigo after changing head position
  • No associated hearing loss or fullness feeling in the ear
  • Some nausea, but usually not severe and usually not associated with vomiting
  • Vertigo stops as soon as you turn your head away from the provoking position and back to where it was
• Types of benign paroxysmal positional vertigo
  • Posterior canal benign paroxysmal positional vertigo
    • dislodged inner ear particles in the posterior semicircular canal abnormally influence the balance system producing vertigo, most commonly diagnosed with the Dix-Hallpike test.
  • Lateral canal benign paroxysmal positional vertigo
    • dislodged inner ear particles in the lateral semicircular canal abnormally influence the balance system producing the vertigo, most commonly diagnosed by the supine roll test.
• Procedures used to diagnose benign paroxysmal positional vertigo
  • Dix-Hallpike Maneuver
  • Supine roll test
• Treatment options include:
  • Canalith Repositioning Procedure: also called Epley or Semont maneuvers, performed in your doctor's office or by your physical therapist. It involves putting you into a position that causes vertigo, allowing it to pass, and then turning your head carefully to move those tiny crystals in your inner ear to a position where they won’t do any harm.
  • Observation: offers the potential benefits of avoiding provocation of new symptoms and any discomfort associated with the repositioning maneuvers themselves. If you and your healthcare provider elect observation it is important that you know that.
    • Symptoms may last longer than they would if you received treatment.
    • There is a higher possibility of recurrence of another episode.
  • Vestibular rehabilitation: exercises to treat dizziness and balance disorders.
  • Medications are NOT routinely used to treat benign paroxysmal positional vertigo since they do not address the cause and can delay the brain's ability to compensate and recover.

What is BPPV?

Benign paroxysmal positional vertigo (BPPV) is the most common inner ear problem and cause of vertigo, or false sense of spinning. BPPV is a specific diagnosis, and each word describes the condition:

• Benign—it is not life-threatening, even though the symptoms can be very intense and upsetting
• Paroxysmal (par-ek-siz-muhl)—it comes in sudden, short spells
• Positional—certain head positions or movements can trigger a spell
• Vertigo—feeling like you are spinning or the world around you is spinning

What causes BPPV?

Crystals of calcium carbonate are a normal part of our inner ear and help us with our balance and body motion. These tiny rocklike crystals, or “otoconia” (oh-toe-cone-ee-uh), are settled in the center “pouch” of the inner ear. BPPV is caused by the crystals becoming “unglued” from their normal place. They begin to float around and/or get stuck on sensors in the wrong (canal) part of the inner ear. The most intense part of your BPPV symptoms has to do with how long it takes the crystal/sensor to settle after you move or change your head or body position. As the crystals move and settle, your brain is getting powerful (false) messages that you are violently spinning when all you may have done is lay down or rolled over in bed.

What are the common symptoms, and how can BPPV affect me?

Everyone will experience BPPV differently, but there are common symptoms. The most common symptoms are distinct triggered spells of vertigo or spinning sensations. You may experience nausea (sometimes vomiting) and/or a severe sense of disorientation in space. You may also feel unstable or that you are losing your balance. These symptoms will be intense for seconds to minutes. You can have lasting feelings of dizziness and instability, though at a lesser level, once the episode has passed. In some people, especially seniors, BPPV can appear as an isolated sense of instability brought on by position change, such as sitting up, looking up, bending over, or reaching. BPPV does not cause constant severe vertigo unaffected by position or movement. Neither does BPPV affect your hearing or cause you to faint. The natural course of BPPV is to become less severe over time. People will often report that their very first BPPV spinning episode was the worst, and the following episodes were not as bad.

How common is BPPV?

BPPV is very common. It is more common in older people. Many of us will experience it at some time in our lives.

What caused my BPPV?

Most cases of BPPV happen for no reason. It can sometimes be associated with trauma, migraine, other inner ear problems, diabetes, osteoporosis, and lying in bed for long periods (preferred sleep side, surgical procedures, illness).

How is BPPV diagnosed?

Ordinary medical imaging, such as scans and x-rays, or medical laboratory testing cannot confirm BPPV. Your health care provider or examiner will complete simple bedside testing to help confirm your diagnosis. Bedside testing requires the examiner to move your head into a position that makes the crystals move. The testing may include hanging your head a little off the edge of the bed or rolling your head left and right while lying in bed. The examiner will be watching you for a certain eye movement to confirm your diagnosis. The most common tests are called either the Dix-Hallpike test or supine roll test.

Can BPPV be treated?

Yes. Although medications are not used other than for relief of immediate distress, such as nausea, most BPPV cases can be corrected with bedside repositioning exercises that take only a few minutes to complete. They have high success rates (around 80%) with only 1-3 treatments. These maneuvers are designed to guide the crystals back to their original location in your inner ear. They can be done at the same time that the bedside testing for diagnosis is being performed. You might be sent to a health professional (medical provider, audiologist, or therapist) who can perform these maneuvers, especially if any of the following apply:

• You have severe disabling symptoms.
• You are a senior with a history of past falls or fear of falling.
• You have difficulty moving around, such as joint stiffness, especially in your neck and back and/or weakness.

You can also be taught to perform these maneuvers by yourself with supervision, which is called “self-repositioning.”

Is there any downside to BPPV repositioning treatments?

During the actual BPPV treatment, there can be some brief distress from vertigo, nausea, and feelings of disorientation as you usually have with your BPPV episodes. Following the treatment, some people report that their symptoms start to clear right away. Many others report that they have continuing motion sickness–type symptoms and mild instability. These symptoms can take a few hours or a few days to go away.

Can BPPV go away on its own?

There is evidence that if BPPV is left untreated, it can go away within weeks. However, remember that while the crystal is out of place, in addition to feeling sick and sensitive to motion, your unsteadiness can increase your risk for falling. You will need to take precautions not to fall. You are at a higher risk of injury if you are a senior or have another balance issue. Seniors are encouraged to seek professional help quickly to help to resolve symptoms.

How do I know that my BPPV has gone away?

The strong spinning sensations that have been triggered by position changes should be greatly reduced, if not completely gone.

How long will it take before I feel better?

You can still feel a little bit sensitive to movement even after successful treatments for BPPV. You can also feel unsteady at times. These mild symptoms can take a few days to a few weeks to go away. You should follow up with your medical provider or therapist if your symptoms of dizziness or instability do not get better in a few days to a couple of weeks. Seniors with a history of falls or fear of falling may need further exercises or balance therapy to clear BPPV completely.

Is there anything that I should or should not do to help my BPPV?

Yes. Your balance will be “off,” so you will need to take precautions that you do not fall. You will feel more sensitive to movement until the BPPV has been successfully treated and healed. When your symptoms have gone away, it is important to return to normal activities that you can do safely. Exposure to motion and movement will help to speed your healing.

Can BPPV come back, and/or can I prevent it?

Unfortunately, BPPV is a condition that can sometimes return. Your risk for BPPV returning can shift from low risk (few experiences in your lifetime) to a higher risk, which is often caused by some other factor, such as trauma (physical injury), other inner ear or medical conditions, or aging. Medical research has not found any way to stop BPPV from coming back, but it can be treated with a high rate of success.

What happens if I still have symptoms following my initial treatments?

There are a number of reasons why your initial treatment could have failed:

1. It is not uncommon to need more than one repositioning session to get the crystals back in their proper place. You may need only a few more treatments.
2. There are a number of different types of BPPV that can require special treatment. The self-treatment is designed for the most common form of BPPV. There are a number of other treatments available that depend on the different types of BPPV.
3. BPPV can sometimes be in more than one canal and/or side at the same time. This would require multiple treatments to resolve.
4. If initial attempts at repositioning have failed, mainly if you have tried only self-repositioning, seek a health professional who specializes in BPPV. It can be difficult to complete correct positioning by yourself. A professional may be able to complete better positioning and/or use helpful equipment.
5. There can be some significant leftover dizziness even after the BPPV crystals have been correctly repositioned. This dizziness may require more time (a few days to a couple of weeks), or it may be appropriate for a different exercise/movement routine. It is very important to follow-up with your health care provider if you continue to have symptoms. You may be sent for further testing to confirm your diagnosis and/or discuss further treatment options.