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Benign Paroxysmal Positional Vertigo (BPPV)

feeling dizzy when you roll over in bed or get up from laying position? Could be BPPV!

What is BPPV?

Benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness and type of vertigo. The condition is characterized by brief episodes of dizziness, nausea, nystagmus (eyes involuntarily moving side to side) triggered by a certain movement of the head. BPPV can be resolved through a canalith repositioning maneuver, which may be performed by a chiropractor.

Over 7% of the population may experience BPPV at some point in their life and 80% of those people will require a medical consultation. Although this condition can affect any age group, it is most commonly found within the fourth or fifth decade of life. Since this condition is common in the elderly population it will often go unreported.

Additional risk factors for the development and recurrence of BPPV include a sedentary lifestyle, diabetes mellitus, hyperinsulinemia, hyperglycemia, hypertension, hyperlipidemia, osteoporosis, nutritional deficiencies, particularly vitamin D deficiency.

The anatomy of the ear that are included with this condition are three semicircular canals, each filled with a viscous fluid called endolymph. As the head moves the fluid moves within those canals. This stimulation is then transmitted to the brain, while working with input from the eyes and your cervical proprioception, to help with balance. BPPV develops when calcium carbonate particles (crystals) dislodge within one of these canals.

A majority of benign paroxysmal positional vertigo cases have an idiopathic origin. There are other issues that can cause this condition including cranial trauma, infection, ovarian hormonal dysfunction, syphilis, psychological disorders, cardiovascular disease, and more. BPPV patients may have vascular abnormalities that contribute to this condition.


A classic for BPPV includes sudden episodes of rotary vertigo that last about 10-20 seconds following different movements of the head. Typical activities that provoke this include transitioning between upright and recumbent (laying down), rolling from side to side, bending forward, and moving head to look up, down, or side to side. Benign paroxysmal positional vertigo symptoms are generally episodic, provoked by movement and eased with maintaining a stable position.

BPPV is often accompanied by an increased anxiety, impaired postural control, and a reduced quality of life.


The diagnosis of BPPV is generally established with a history and clinical examination. Diagnostic imaging such as thin section CT and MRI typically have no findings when it comes to BPPV, however it can rule out other intracranial pathologies, as well as internal auditory abnormalities.

Clinicians may assess vital signs to provide further insight. Blood pressure measurements may help identify patients that are predisposed due to hypertension or orthostatic hypotension. Clinicians will also palpate (touch) the head and neck for any signs of lymph node swelling.

Otoscopic (tool to look inside the ear) evaluation may be used to identify any middle ear problems.


The current standard for BPPV is a repositioning maneuver done with a clinician and home-based exercises. This maneuver is called the Epley maneuver and is done in the presence of a clinician to reposition the crystals in the ear that are causing the imbalance (vertigo) issues. The effectiveness of the Epley maneuver ranges between 78-95 %.

Management is centered around which semicircular canal the issue is in and then choosing the correct way to maneuver the body to reposition those crystals. All repositioning maneuvers attempt to move the head into a position where the crystals fall back into their normal position.

When performing these repositioning maneuvers, movements should be quick in order to generate enough momentum to replace the dislodged crystals. Patients should be aware that these crystals are moving which will cause them to be dizzy during testing and/or treatment. The patient should attempt to keep their eyes open and remember that the intervention will ultimately help ease their symptoms.

Following the repositioning maneuver the retest with the previously done movement to confirm improvement were made. If symptoms do not completely resolve then the patient may need to repeat multiple repositioning maneuvers within the same session. There should be a 15 minute time period between each movement to ensure the crystals do not get displaced in other positions.

Persistent and long lasting symptoms may require multiple repositioning sessions spaced between one day to one week apart. Following resolution of symptoms clinician will ask patient to come in a month later to reassess and confirm resolution of those symptoms. The follow up is important due to the possibility of symptom redevelopment are common.

A delay between initial symptoms and seeking clinician help leads to higher rates of recurrence. At least half of the patients with recurrent BPPV also suffer from repetitive migraine headaches.

Patients should be encouraged to sleep with the affected side up, as this shows lower rates of recurrence. Home rehabilitation may reportedly resolve symptoms in 98% of BPPV cases within two weeks. Medical management of BPPV (antihistamines, etc) is not recommended.

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