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Benign Paroxysmal Positional Vertigo Differential Diagnoses

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

Diagnostic Considerations

Differential diagnoses for benign paroxysmal positional vertigo (BPPV) can be divided into 3 main areas of pathology: labyrinthine, vestibular nerve, and central sites of lesions. These are subdivided further as follows:

  • Ménière disease is probably the most frequent misdiagnosis applied to chronic BPPV because patients may fail to recognize the positional provocation. It is also confusing because BPPV can occur concomitantly.
  • Inner ear concussion may cause transient positional vertigo and nystagmus and can be confused with BPPV.
  • Alcohol intoxication can cause positional nystagmus, is persistent in a given position, and varies according to head position.
  • With labyrinthitis, the nystagmus is spontaneous, persistent, predominantly linear-horizontal and affected little by head position. Caloric testing often reveals unilateral weakness.
  • For vascular loop syndrome, the diagnostic criteria have been defined poorly. This diagnosis should be considered only after all other possibilities are exhausted.
  • Positional nystagmus of central origin is seldom transient and may be down-beating, whereas BPPV is usually up-beating. Frequently, other CNS signs are present.
  • Positional down-beating nystagmus is often associated with a lesion of the nodulus (which normally inhibits vertical vestibuloocular reflex gain) from stroke, multiple sclerosis, Arnold-Chiari malformation, ischemia, cerebellar degeneration, and intoxication.
  • Central positional nystagmus may indicate a posterior fossa lesion such as acoustic neuroma or meningioma.
  • Vertebral artery insufficiency is also a differential diagnosis for BPPV.
  • Cervical vertigo, or head extension vertigo, is a somewhat ill-defined entity of symptoms that arises with head extension, quite possibly a manifestation of vascular compression (vertebral arteries).
  • With orthostatic hypotension, low blood volume or poor systemic arterial tone can account for hypoperfusion of the brain and cause dizziness. Patients feel better when lying down and are symptomatic when sitting up.

Differential Diagnoses

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.

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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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