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Benign Paroxysmal Positional Vertigo (BPPV)

Most common cause of peripheral vertigo, characterized by brief episodes of spinning sensation triggered by head position changes, caused by displaced otoconia in the semicircular canals, diagnosed by Dix-Hallpike or supine roll test, and treated with canalith repositioning maneuvers (Epley, Semont, BBQ roll).

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

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What is Benign Paroxysmal Positional Vertigo (BPPV)?

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo, accounting for 17-42% of vestibular disorders. Pathophysiology involves displacement of otoconia (calcium carbonate crystals) from the utricular macula into the semicircular canals (canalithiasis, free-floating otoconia, 90%) or adherent to the cupula (cupulolithiasis, 10%). The posterior semicircular canal is involved in 85-95% of cases due to its dependent position, followed by horizontal canal (5-15%) and rarely anterior canal (<2%).

Diagnosis is clinical, based on history of brief positional vertigo (<60 seconds) triggered by lying down, rolling over, looking up, or bending forward, plus characteristic findings on positional testing. Dix-Hallpike maneuver is diagnostic for posterior canal BPPV, eliciting upbeat-torsional (geotropic) nystagmus with latency 5-20 seconds, duration <60 seconds, fatigability with repetition, and reversal direction on returning upright. Supine roll test (Pagnini-McClure) is used for horizontal canal BPPV, showing geotropic (canalithiasis) or apogeotropic (cupulolithiasis) horizontal nystagmus.

Treatment is canalith repositioning maneuvers (CRM). Epley maneuver is first-line for posterior canal BPPV (85-95% success after 1-3 sessions): sequential head positions move otoconia from the canal back to the utricle. Semont liberatory maneuver is alternative. For horizontal canal: BBQ roll (Lempert) maneuver for geotropic, Gufoni or forced prolonged position for apogeotropic. Vestibular suppressants (meclizine, dimenhydrinate) are NOT recommended as they can interfere with central compensation. Vestibular rehabilitation (Brandt-Daroff exercises) for residual symptoms or recurrent disease. Recurrence rate 15-50% within 5 years; secondary BPPV may follow head trauma, vestibular neuritis, or migraine.

Symptoms

Brief episodes of spinning vertigo (<60 seconds)
Triggered by head position changes (lying down, rolling, looking up)
Nausea, sometimes vomiting during attacks
Imbalance and lightheadedness between attacks
Symptoms triggered by getting in/out of bed
No hearing loss, no tinnitus, no aural fullness
Attacks worse in morning, may resolve as day progresses

Risk Factors

Age >50 years (incidence increases with age)
Female sex (2-3:1 female:male)
Head trauma (most common secondary cause)
Vestibular neuritis, labyrinthitis
Vitamin D deficiency
Osteopenia, osteoporosis
Migraine, vestibular migraine
Prolonged bed rest, recent surgery

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Recurrent positional vertigo episodes
  • Vertigo associated with hearing loss or tinnitus
  • Persistent imbalance, falls
  • Vertigo with neurological symptoms (diplopia, weakness)
  • Severe nausea, vomiting, dehydration
  • Failed self-administered repositioning maneuvers
  • Symptoms after head trauma

Treatment Methods

01
Epley canalith repositioning maneuver (posterior canal, first-line)
02
Semont liberatory maneuver (alternative for posterior canal)
03
BBQ roll (Lempert) maneuver for horizontal canal geotropic
04
Gufoni maneuver for apogeotropic horizontal canal BPPV
05
Brandt-Daroff exercises for home management of recurrence
06
Avoid vestibular suppressants (interfere with compensation)
07
Antiemetics (ondansetron) for severe nausea, short term only
08
Vestibular rehabilitation for residual imbalance
09
Vitamin D supplementation if deficient
10
Surgical posterior canal occlusion (rare, refractory cases)

Which Department to Visit?

You can visit our KBB (Kulak Burun Boğaz) department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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