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Benign Paroxysmal Positional Vertigo Clinical Presentation

  • Author: John C Li, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: May 06, 2016


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  • The onset of benign paroxysmal positional vertigo (BPPV) is typically sudden. Many patients wake up with the condition, noticing the vertigo while trying to sit up suddenly. Thereafter, propensity for positional vertigo may extend for days to weeks, occasionally for months or years. In many, the symptoms periodically resolve and then recur.
  • The severity covers a wide spectrum. In patients with extreme cases, the slightest head movement may be associated with nausea and vomiting. Despite strong nystagmus, other patients seem relatively unfazed.
  • People who have BPPV do not usually feel dizzy all the time. Severe dizziness occurs as attacks triggered by head movements. At rest between episodes, patients usually have few or no symptoms. However, some patients complain of a continual sensation of a "foggy or cloudy" sensorium.
  • Classic BPPV is usually triggered by the sudden action of moving from the erect position to the supine position while angling the head 45° toward the side of the affected ear. Merely being in the provocative position is not enough. The head actually must move to the offending pose. After reaching the provocative position, a lag period of a few seconds occurs before the spell strikes. When BPPV is triggered, patients feel as though they are suddenly thrown into a rolling spin, toppling toward the side of the affected ear. Symptoms start very violently and usually dissipate within 20 or 30 seconds. This sensation is triggered again upon sitting erect; however, the direction of the nystagmus is reversed.


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  • The physical examination findings in patients affected by BPPV are generally unremarkable. All neurotologic examination findings except those from the Dix-Hallpike maneuver may be normal. However, the presence of neurotologic findings does not preclude the diagnosis of BPPV.
  • The Dix-Hallpike maneuver is the standard clinical test for BPPV. The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless except to indicate that active canalithiasis is not present at that moment.
    • This test is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.
    • Dix-Hallpike maneuver tips include the following:
      • Do not turn the head 90° since this can produce an illusion of bilateral involvement.
      • Tailor briskness of the Dix-Hallpike test to the individual patient.
      • Consider the Epley modification. From behind the patient, performing the maneuver is easier, since one can pull the outer canthus superolaterally to visualize the eyeball rotation.
      • In typical nystagmus, the axis is near the undermost canthus. Minimize suppression by directing the patient gaze to the anticipated axis of rotation.
  • Classic posterior canal BPPV produces geotropic rotatory nystagmus. The top pole of the eyes rotates toward the undermost (affected) ear.
  • Purely horizontal nystagmus indicates horizontal canal involvement.
  • Sustained or nonfatiguing nystagmus may indicate cupulolithiasis rather than canalithiasis.

A study by Yetiser and Ince indicated that the head-roll maneuver is the most effective positioning test for diagnosing lateral canal BPPV, in a comparison with the head-bending and lying-down positioning tests. The study, which involved 78 patients with lateral canal BPPV, found that using the head-roll maneuver, the affected side was located in 75% of patients with apogeotropic nystagmus and in 95.6% of patients with geotropic nystagmus.[3]



A few factors predispose patients to BPPV. These include inactivity, acute alcoholism, major surgery, and central nervous system (CNS) disease. A complete neurotologic examination is important because many patients have concomitant ear pathology, as follows:

  • Idiopathic pathology - 39%
  • Trauma - 21%
  • Ear diseases - 29%
  • Otitis media - 9%
  • Vestibular neuritis - 7%
  • Ménière disease - 7%
  • Otosclerosis - 4%
  • Sudden sensorineural hearing loss - 2%
  • CNS disease - 11%
  • Vertebral basilar insufficiency - 9%
  • Acoustic neuroma - 2%
  • Cervical vertigo - 2%

A study by Chang et al suggested that BPPV can be triggered by dental procedures. The study, which included 768 patients with BPPV and 1536 controls, found that within 1 month before they were diagnosed, 9.2% of the patients with BPPV had undergone dental treatment, compared with 5.5% of controls within a month before they were identified. Adjustments for demographic factors and comorbidities indicated that a positive relationship exists between recent dental procedures and BPPV.[4]

A retrospective study by Faralli et al indicated that in persons with migraine headache and BPPV, the onset of BPPV tends to occur earlier in life than it does in patients with this form of vertigo but no migraine. The investigators found that the mean age at BPPV onset for patients with migraine was 39 years, compared with 53 years for patients without migraine. In addition, highly recurrent BPPV was found in 19.4% of the migraine patients, compared with 7.3% of persons without migraine. Moreover, the frequency of atypical eye movements and Ménière-like vertigo was greater in patients with both migraine and highly recurrent BPPV. Faralli and colleagues stated, however, that it has not yet been determined whether a direct pathophysiologic association exists between migraine and BPPV.[5]

Contributor Information and Disclosures

John C Li, MD Private Practice in Otology and Neurotology; Medical Director, Balance Center

John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Neurotology Society, American College of Surgeons, American Medical Association, American Tinnitus Association, Florida Medical Association, North American Skull Base Society

Disclosure: Received consulting fee from Synthes Power Tools for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Auditory Society, The Triological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Michael E Hoffer, MD Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego

Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Received royalty from American biloogical group for other.


John Epley, MD Director, Portland Otologic Clinic

John Epley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Oregon Medical Association

Disclosure: Nothing to disclose.

  1. Anagnostou E, Kouzi I, Spengos K. Diagnosis and Treatment of Anterior-Canal Benign Paroxysmal Positional Vertigo: A Systematic Review. J Clin Neurol. 2015 May 28. [Medline].

  2. Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1980 Sep-Oct. 88(5):599-605. [Medline].

  3. Yetiser S, Ince D. Diagnostic Role of Head-Bending and Lying-Down Tests in Lateral Canal Benign Paroxysmal Positional Vertigo. Otol Neurotol. 2015 May 1. [Medline].

  4. Chang TP, Lin YW, Sung PY, Chuang HY, Chung HY, Liao WL. Benign Paroxysmal Positional Vertigo after Dental Procedures: A Population-Based Case-Control Study. PLoS One. 2016. 11 (4):e0153092. [Medline]. [Full Text].

  5. Faralli M, Cipriani L, Del Zompo MR, et al. Benign paroxysmal positional vertigo and migraine: analysis of 186 cases. B-ENT. 2014. 10(2):133-9. [Medline].

  6. Shim DB, Kim JH, Park KC, Song MH, Park HJ. Correlation between the head-lying side during sleep and the affected side by benign paroxysmal positional vertigo involving the posterior or horizontal semicircular canal. Laryngoscope. 2012 Feb 16. [Medline].

  7. Picciotti PM, Lucidi D, De Corso E, Meucci D, Sergi B, Paludetti G. Comorbidities and recurrence of benign paroxysmal positional vertigo: personal experience. Int J Audiol. 2016 May. 55 (5):279-84. [Medline].

  8. [Guideline] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008 May 27. 70(22):2067-74. [Medline]. [Full Text].

  9. [Guideline] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov. 139(5 Suppl 4):S47-81. [Medline]. [Full Text].

  10. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992 Sep. 107(3):399-404. [Medline].

  11. Fung K, Hall SF. Particle repositioning maneuver: effective treatment for benign paroxysmal positional vertigo. J Otolaryngol. 1996 Aug. 25(4):243-8. [Medline].

  12. Herdman SJ, Tusa RJ, Zee DS, et al. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. 1993 Apr. 119(4):450-4. [Medline].

  13. Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. 1995 Jun. 112(6):670-5. [Medline].

  14. Li JC, Epley J. The 360-degree maneuver for treatment of benign positional vertigo. Otol Neurotol. 2006 Jan. 27(1):71-7. [Medline]. [Full Text].

  15. Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. 1996 Apr. 25(2):121-5. [Medline].

  16. Roberts RA. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo.

  17. Roberts RA. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo.

  18. Smouha EE, Roussos C. Atypical forms of paroxysmal positional nystagmus. Ear Nose Throat J. 1995 Sep. 74(9):649-56. [Medline].

  19. Weider DJ, Ryder CJ, Stram JR. Benign paroxysmal positional vertigo: analysis of 44 cases treated by the canalith repositioning procedure of Epley. Am J Otol. 1994 May. 15(3):321-6. [Medline].

The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.
The patient is then brought back up to the sitting position.
Next, the patient is rolled 180° from the affected side to the opposite side. Note that the position of the head is 45° toward the affected side before the roll. The head winds up facing down, 180° away from the starting position.
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