Vertigo

What is BPPV?

Benign paroxysmal positional vertigo (BPPV) is a disease of the vestibular (balance ) system of your inner ear. When you change your head position, it causes vertigo. Vertigo is a feeling that the room is spinning around you, that you are moving within the room, or that you are off-balance or tilting.

Your vestibular system helps sense motion and changes in space. It adds to your sense of balance. The vestibular organs are inside the innermost part of your ear. They include the utricle, saccule, and 3 semicircular canals. When your head moves, these small organs send this information to the brain.

The utricle contains small calcium crystals. These help you to sense motion. Sometimes these crystals detach from the utricle and land in one of the semicircular canals. Then the canals may send the wrong signals to the brain, especially when the crystals move. This confuses the brain and leads to BPPV symptoms.

The condition is called benign because it's not life-threatening. It does not get worse with time. Paroxysmal means that the vertigo comes and goes. Positional just means that symptoms come from a change in head position.

BPPV is fairly common, especially in women. Older adults have it more often but people of any age can get it. It's one of the most common vestibular disorders.

What causes BPPV?

Anything that dislodges the crystals from the utricle can cause BPPV. Having a past head injury is a major cause. Most of the time, BPPV is thought to be because of aging of the inner ear. In most cases, no one knows exactly why some people get BPPV and others don't.

Who is at risk for BPPV?

People with certain health conditions may have a higher risk for BPPV. But often the cause is not known. You may have a higher risk of developing BPPV if you have any of these:

• Migraine
• 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.

What are the symptoms of BPPV?

The most common BPPV symptoms include:

• A feeling of spinning (vertigo) or movement
• Trouble with balance
• Nausea and vomiting

Certain types of movement can bring on symptoms. Symptoms then often last a minute or less. Common triggers are rolling over in bed or looking up while standing. These symptoms can vary in how often they happen and how severe they are. In some people, these symptoms are so severe that they disrupt personal and work life.

Very often, the symptoms go away and then come back weeks or months later. Without treatment, symptoms might continue for a few weeks before going away. In a small number of people, the symptoms never come back after the first time.

Unlike some other causes of vertigo, BPPV doesn't cause nervous system symptoms such as severe headache, speech problems, or loss of limb movement. It also doesn't cause hearing problems.

The symptoms of BPPV may seem like those of other health conditions. Always see your healthcare provider for a diagnosis.

How is BPPV?

BPPV may be diagnosed and treated by your primary healthcare provider, an ear, nose, and throat (ENT) doctor (otolaryngologist), a neurologist, or often an emergency room healthcare provider. The provider will ask about your health history. You may also have a physical exam. This may include hearing and balance tests. It will also include an exam of the nervous and cardiovascular systems. Problems with these systems can also cause vertigo.

As part of the exam, your healthcare provider may have you do certain movements. These will include moving your head and body in certain ways. If you have BPPV, this test can bring on vertigo. It can also bring on quick, involuntary eye movements (nystagmus). Your provider can also use this test to find which semicircular canal is most likely affected.

If your healthcare provider is still not sure about the diagnosis, you may need other tests such as:

• ENG (electronystagmography). This test uses electrodes to test your eye movements in response to stimuli that may cause your vertigo.
• VNG (videonystagmography). This test is similar to an ENG but it uses cameras instead. Your eyes are a part of your sense of balance. So ENG and VNG tests may help find the cause of your vertigo.
• Imaging tests. Tests such as an MRI can help rule out nervous system problems as a cause.

How is BPPV treated?

Treatment will depend on your symptoms, age, and general health. It will also depend on how bad the condition is.

First your healthcare provider may try to move the calcium crystals out of your semicircular canals with what's called an "Epley maneuver." This may be done with a series of specific head and neck movements. This often takes about 15 minutes. Your provider may tell you to do specific movements at home. This treatment often works. Some people may still have vertigo with head movement for a few weeks.

Your treatment may also include special physical therapy (vestibular rehabilitation).

Medicines are not often given for BPPV. This is because most of them don't help. In some cases, short-term use of motion sickness medicines may help to ease related nausea.

If these other treatments fail, in rare cases your healthcare provider may advise surgery. One option is called posterior canal plugging. It blocks the movement of calcium crystals in the posterior semicircular canal. The surgery can work well. But in rare cases, it can cause some hearing loss.

Your healthcare provider may also advise a watch-and-wait approach to your BPPV before trying surgery. BPPV often goes away on its own over time. But in many cases it does come back. If you are still having symptoms from BPPV, your healthcare provider may tell you ways to avoid symptoms. For example:

• Using 2 pillows in bed to raise your head
• Not sleeping on your affected side
• Rising slowly out of bed
• Not looking up
• Not bending over to pick things up
• Not doing exercises that use head rotation, such as swimming laps

Even if you stop having symptoms, your healthcare provider may suggest that you follow similar instructions, at least for a few weeks. This may help prevent your symptoms from coming back.

Key points about BPPV

• BPPV is a disease that affects the vestibular system of the inner ear. With changes of head position, it causes sudden vertigo and related symptoms.
• Head injury and past vestibular disorders can cause BPPV. But many times the cause is not known.
• Symptoms typically happen with head movement. The vertigo lasts only a short while, but it may come back many times.
• BPPV often responds to treatment with specific physical movements. But in rare cases some people with severe BPPV may need surgery.
• As you are recovering from BPPV, you may need to avoid certain head movements to help prevent your symptoms from coming back.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.