Summary

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of peripheral vertigo, accounting for approximately 20-30% of all patients presenting with dizziness. It is caused by displaced otoconia (calcium carbonate crystals) from the utricle that migrate into one of the semicircular canals – most commonly the posterior canal (~85% of cases). When the head moves into certain positions, these crystals move within the canal, causing abnormal endolymph flow and stimulating the vestibular hair cells, resulting in brief, intense vertigo and characteristic rotatory nystagmus. The hallmark is vertigo triggered by specific head movements (e.g., rolling over in bed, looking up) lasting less than one minute. Diagnosis is clinical using the Dix-Hallpike manoeuvre (for posterior canal) or Supine Roll Test (for horizontal canal). Treatment is highly effective with canalith repositioning manoeuvres such as the Epley manoeuvre, which physically repositions the crystals out of the canal.

Key Facts

• Prevalence: Most common cause of vertigo (~20-30% of dizzy patients).
• Mechanism: Otoconia (Crystals) displaced into semicircular canal (usually posterior).
• Duration of Vertigo: Seconds to <1 minute (Paroxysmal).
• Trigger: Head position change (Lying down, Rolling over, Looking up, Bending forward).
• Nystagmus: Rotatory (Torsional) towards affected ear, Up-beating, Fatigable. Latency 1-5 seconds.
• Diagnosis: Dix-Hallpike Manoeuvre (Positive = Rotatory nystagmus with vertigo).
• Treatment: Epley Manoeuvre (90% success). NO role for vestibular sedatives.
• Prognosis: Excellent. Self-limiting in many. High recurrence rate (~50% over 5 years).

Clinical Pearls

"Brief is Beautiful": BPPV vertigo lasts seconds to under a minute. If vertigo is continuous for hours or days, think Vestibular Neuritis, Meniere's, or Central cause.

"The Dix-Hallpike is the Test": A positive Dix-Hallpike (rotatory, up-beating nystagmus with latency) is diagnostic. You do not need imaging.

"Epley is the Treatment – Not Pills": Vestibular sedatives (Prochlorperazine, Betahistine) do NOT treat BPPV. The Epley manoeuvre repositions crystals. Pills just sedate the patient.

"HINTS Beats CT for Stroke": In Acute Vestibular Syndrome, the HINTS exam (Head Impulse, Nystagmus type, Test of Skew) is more sensitive for stroke than CT head (93% vs 16% sensitivity).

Why This Matters Clinically

BPPV is extremely common and often misdiagnosed. Recognising the classic history (brief, positional vertigo), performing a Dix-Hallpike, and treating with an Epley can cure the patient in a single consultation. Conversely, missing central causes (e.g., posterior circulation stroke) can be fatal.

The Dix-Hallpike Manoeuvre (Posterior Canal BPPV)

Gold Standard Test. MUST know this.

Technique:

1. Patient sits upright on bed. Head turned 45° towards the side being tested.
2. Rapidly lower patient backwards so head hangs 20-30° below horizontal (off bed end), maintaining 45° rotation.
3. Observe eyes for nystagmus. Ask about vertigo.
4. Hold position for 30-60 seconds.
5. Return patient to sitting. Observe for reversal nystagmus.
6. Repeat on other side.

Positive Test (Posterior Canal BPPV):

Supine Roll Test (Horizontal Canal BPPV)

For suspected Horizontal Canal BPPV.

Technique:

1. Patient lies supine, head neutral.
2. Turn head 90° to one side. Observe for nystagmus. Hold 30-60 seconds.
3. Return to neutral. Turn head 90° to other side. Observe. Compare.

Interpretation:

Neurological Examination

Essential to exclude central causes.

Red Flags: HINTS Examination (Acute Vestibular Syndrome)

For continuous vertigo – NOT for BPPV (which is episodic).

Remember: HINTS "INFARCT" = Normal Head Impulse, Fast-phase Alternating, Refixation on Cover Test.

• Resolution: Most resolve spontaneously within weeks-months.
• Epley Success: ~90% cure with 1-2 manoeuvres.
• Recurrence: ~50% recur within 5 years. 15% recur within 1 year.
• Quality of Life: Significant impact during active episodes. Full return to normal expected.

Differential Diagnosis Summary Table

Medications: When They ARE and ARE NOT Indicated

Driving Advice (UK DVLA)

Why Vestibular Rehabilitation May Help

For persistent symptoms or recurrent BPPV.

Key Guidelines

Evidence for Epley

Scenario 1:

• Stem: A 55-year-old woman complains of brief episodes of room-spinning vertigo when she rolls over in bed. Each episode lasts about 30 seconds. No hearing loss or tinnitus. What is the most likely diagnosis and how would you confirm it?
• Answer: BPPV. Confirm with Dix-Hallpike Manoeuvre (Expect up-beating, torsional nystagmus towards affected ear with latency and fatigability).

Scenario 2:

• Stem: You perform a Dix-Hallpike and observe up-beating, rotatory nystagmus towards the right ear after a 3-second delay. What is the diagnosis and treatment?
• Answer: Right Posterior Canal BPPV. Treatment: Right Epley Manoeuvre.

Scenario 3:

• Stem: What are the key features differentiating BPPV from Vestibular Neuritis?
• Answer: BPPV: Brief (<1 min), Triggered by position, Positive Dix-Hallpike. Vestibular Neuritis: Continuous vertigo (Days), Not positional, Positive Head Impulse Test, No hearing loss.

Scenario 4:

• Stem: Describe the HINTS examination and when you would use it.
• Answer: HINTS = Head Impulse, Nystagmus type, Test of Skew. Used in Acute Vestibular Syndrome (Continuous vertigo). A "Dangerous HINTS" (Normal Head Impulse, Direction-Changing/Vertical Nystagmus, Positive Skew) suggests Central cause (Stroke) – More sensitive than CT. NOT used for BPPV.

Scenario 5:

• Stem: A patient with BPPV asks for "those anti-sickness tablets" because they worked before. What is your response?
• Answer: Vestibular sedatives (Prochlorperazine) do NOT treat BPPV. They mask symptoms and delay recovery. The treatment is the Epley manoeuvre, which repositions the crystals causing the problem. I will perform the Epley now.

What is BPPV?

BPPV stands for Benign Paroxysmal Positional Vertigo. It's the most common cause of vertigo (spinning dizziness). It happens when tiny crystals in your inner ear become dislodged and move into the balance canals.

What are the symptoms?

• Brief episodes of intense spinning, usually lasting less than a minute.
• Triggered by specific head movements, like rolling over in bed or looking up.
• You may feel nauseous. There is no hearing loss.

How is it diagnosed?

Your doctor will do a simple test called the Dix-Hallpike manoeuvre. They'll turn your head and lower you back quickly, watching your eyes for a specific type of eye movement (nystagmus) that confirms BPPV.

How is it treated?

Treatment is a physical repositioning manoeuvre called the Epley manoeuvre. This moves the crystals out of the balance canal, and works in about 90% of cases. Tablets like anti-sickness pills do NOT fix BPPV.

Will it come back?

BPPV can recur. About half of people will have another episode within 5 years. Your doctor can show you exercises (Brandt-Daroff) to do at home if it happens again.

Key Counselling Points

1. No Pills Needed: "Tablets won't fix this – the treatment is a physical manoeuvre."
2. High Cure Rate: "The Epley works in 9 out of 10 people."
3. Recurrence: "It may come back, but you can be treated again."
4. Safety: "Be careful for a day or two after treatment, as you may still feel a bit off-balance."

Addressing Anxiety After BPPV

Many patients develop anxiety about vertigo recurring.

Common Mistakes by Patients

Key Counselling Points (Expanded)

1. It's Benign: "BPPV is not dangerous. It's caused by tiny crystals in your ear."
2. Treatment is a Manoeuvre, Not a Pill: "The Epley manoeuvre is the treatment. Tablets won't fix it."
3. Expect ~90% Cure: "9 out of 10 people are cured with one or two treatments."
4. Recurrence is Common: "About half of people get another episode within 5 years."
5. Teach Self-Treatment: "If it comes back, you can learn to do exercises at home (Brandt-Daroff)."
6. When to Return: "Come back if vertigo doesn't resolve, if it's continuous, or if you have new symptoms like hearing loss or headache."

Quality of Life Impact

• 1980: Dr. John Epley, an American ENT surgeon, developed the Epley Manoeuvre.
• Initial Skepticism: The manoeuvre was initially met with skepticism (otoconia in the canal was not proven).
• Validation: Studies confirmed the mechanism and efficacy.
• Legacy: The Epley is now the Gold Standard treatment for posterior canal BPPV worldwide.