Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo — the sudden sensation that you’re spinning or that the inside of your head is spinning.
BPPV causes brief episodes of mild to intense dizziness. It is usually triggered by specific changes in your head’s position. This might occur when you tip your head up or down, when you lie down, or when you turn over or sit up in bed.
Although BPPV can be bothersome, it’s rarely serious except when it increases the chance of falls. You can receive effective treatment for BPPV during a doctor’s office visit.
Benign paroxysmal positional vertigo – Pathophysiology
To understand pathophysiology, an understanding of normal SCC anatomy and physiology is necessary. Each inner ear contains 3 SCCs oriented in 3 perpendicular planes; the SCCs mediate spatial orientation. Each canal consists of a tubular arm (crura) that sprouts from a large barrellike compartment, much like the handle of a coffee mug sprouts from the mug. Each of these arms has a dilated (ampullary) end located near the top or front portion that houses the crista ampullaris (nerve receptors).
The crista ampullaris has a sail-like tower, the cupula, that detects the flow of fluid within the SCC. If a person turns suddenly to the right, the fluid within the right horizontal canal lags behind, causing the cupula to be deflected left (toward the ampulla, or ampullopetally). This deflection is translated into a nerve signal that confirms the head is rotating to the right.
In simple terms, the cupula acts as a 3-way switch that, when pressed one way, appropriately gives the body a sensation of motion. The middle or neutral position reflects no motion. When the switch is moved the opposite way, the sensation of motion is in the opposite direction.
Particles in the canal slow and even reverse the movement of the cupula switch and create signals that are incongruous with the actual head movements. This mismatch of sensory information results in the sensation of vertigo.
Causes of benign paroxysmal positional vertigo
Inside the inner ear is a series of canals filled with fluid. These canals are oriented at different angles. When the head is moved, the rolling of the fluid inside these canals tells the brain exactly how far, how fast and in what direction the head is moving.
BPPV is thought to be caused by little calcium carbonate crystals (otoconia) coming loose within the canals. Usually, these crystals are held in special reservoirs within other structures of the inner ear (saccule and utricle). It is thought that injury or degeneration of the utricle may allow the ‘crystals’ to escape into the balance organ and interfere with the fluid flow.
BPPV can be caused by:
- Head injury
- Degeneration of the vestibular system in the inner ear due to ageing
- Damage caused by an inner ear disorder.
There is also an association between BPPV and osteoporosis. However, in a large number of cases, there is no known cause.
Who is at risk for benign paroxysmal positional vertigo?
People with certain health conditions may have a higher risk for BPPV. But many times the cause is not known. You may have a higher risk of developing BPPV if you have any of these:
- Giant cell arteritis
- High blood pressure
- High cholesterol or other blood lipids
- History of stroke
- Head injury
It’s not clear if treating these conditions might reduce your risk for BPPV.
Symptoms of BPPV include:
- Feeling light-headed
- Loss of balance
- Nausea or vomiting
- Vision problems
- nystagmus, which is a medical condition that causes rapid, involuntary eye movements
BPPV symptoms vary among individuals in intensity and duration. A slight change of head position can cause severe symptoms in some people, while rapid or extreme head movements might produce only mild symptoms in others.
Although vertigo usually lasts for less than a minute, other symptoms can last for several days or weeks.
Benign paroxysmal positional vertigo – Possible Complications
- Vertigo can interfere with driving, work, and lifestyle.
- The dizziness of BPPV can make you unsteady, which may put you at greater risk of falling.
- Risk of falling may lead to many injuries, including hip fractures.
Your doctor will ask questions about your general health and your symptoms.
Your doctor will look for the telltale eye movement of nystagmus. They may ask you to lie on your back on a table with your head tilted back off it. This is to show whether you can control your eye movements.
Your doctor also will look to see if symptoms of dizziness happen when your eyes or head moves in a certain direction, and if doing so makes you dizzy for less than a minute. They may use something called Frenzel goggles to detect involuntary eye movements.
Your doctor might also run tests, including:
- Dix-Hallpike test. During this test, a person lies on their back while a doctor rotates their head. These movements should induce vertigo if the person has BPPV. A doctor will also look for rapid eye movements that indicate nystagmus.
- Electronystagmography (ENG) or videonystagmography (VNG). These check your eye movements and how they react to things that might trigger your vertigo.
- Electroencephalogram (EEG). A doctor can use an EEG to measure brain activity and rule out any possible underlying neurological conditions.
- MRI scan. This and other imaging tests may help rule out other causes of your symptoms.
Treatment and home remedies
Treatments for BPPV mainly focus on improving visual stability and reducing vertigo and dizziness.
Effective treatments for BPPV include the following:
The Epley maneuver involves performing a specific series of head movements to dislodge the calcium carbonate crystals from the semicircular canals.
A trained healthcare professional can administer this treatment and teach people how to perform the movements at home.
To do the Epley maneuver:
- Start by sitting on the edge of a bed.
- Turn the head 45 degrees to the right.
- Lie down on the back, keeping the head turned, then hold for 30 seconds.
- Turn the head so that it faces 45 degrees to the left, then hold for 30 seconds.
- Roll the body onto the left side, then hold for 30 seconds.
- Sit up on the left side.
- Repeat these steps on the other side, turning the head to the left first.
Repositioning maneuvers are incredibly useful for treating BPPV.
A doctor may advise a person to keep their head upright for a few days following the procedure. Doing this will prevent the crystals from moving back to the semicircular canals.
These exercises are less effectiveTrusted Source than the Epley maneuver because they do not necessarily remove calcium carbonate crystals from the semicircular canals. Instead, these exercises spread out any buildups. However, Brandt-Daroff exercises can help reduce vertigo symptoms.
To do Brandt-Daroff exercises:
- Begin in an upright, seated position at the edge of a bed.
- Lie down on the left side, turning the head to the right so that the face points toward the ceiling.
- Hold this position for 30 seconds.
- Sit up and return to the starting position.
- Repeat this exercise on the right side.
Some people may feel dizzy or light-headed after completing a set of Brandt-Daroff exercises. If this is the case, they should wait for the dizziness to pass before standing up.
People should stop doing these exercises if they notice new or worsening symptoms.
Medicines do not cure benign paroxysmal positional vertigo (BPPV). But they may be used to control severe symptoms, such as the whirling, spinning sensation of vertigo and the nausea and vomiting that may occur.
Several medications, including common motion sickness remedies, may relieve symptoms of BPPV and may be used for less severe episodes of vertigo or in addition to the Epley maneuvers described above.
- Meclizine (Antivert, Bonine, Dramamine II, D-Vert)
- Diazepam (Valium)
- Dimenhydrinate (Dramamine)
- Promethazine (Phenergan)
- Scopolamine (Isopto, Scopace)
If the cause of vertigo is thought to be due to a viral infection, antiviral medications like acyclovir (Zovirax) may be prescribed.
Steroids like prednisone may be useful if nerve inflammation is a potential reason for vertigo.
This is done less and less often, but rarely, you might need an operation to cure your BPPV. Your surgeon will plug a part of your inner ear to prevent the small calcium crystals from moving in your ear canal. Surgery carries a small chance of complications, including loss of hearing.
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 that’s 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 playing 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.
- 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 keep your balance and improve symptoms of vertigo.
- Stay safe when you have balance problems by adding grab bars near the bathtub and toilet and keeping walking paths clear. This may prevent accidents and injuries.
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.
How to Prevent Benign Paroxysmal Positional Vertigo (BPPV)
- Most cases of BPPV do not have a known cause; therefore, no prevention is possible.
- There may be an association with minor head injury or repeatedly changing head position, for example working with a computer and constantly looking up and down at the monitor.
- As one gets older, it is reasonable to change positions a little more slowly to potentially prevent vertigo.