Benign Positional Vertigo in Emergency Medicine 

Updated: Mar 21, 2018
Author: Andrew K Chang, MD, MS; Chief Editor: Liudvikas Jagminas, MD, FACEP 

Overview

Background

Benign positional vertigo (BPV), also known as benign paroxysmal positional vertigo (BPPV), is the most common cause of vertigo. Vertigo is an illusion of motion (an illusion is a misperception of a real stimulus) and represents a disorder of the vestibular proprioceptive system.

BPV was first described by Adler in 1897 and then by Bárány in 1922; however, Dix and Hallpike did not coin the term benign paroxysmal positional vertigo until 1952. This terminology defined the characteristics of the vertigo and introduced the classic provocative diagnostic test that is still used today. Using positional testing, benign positional vertigo can readily be diagnosed in the emergency department. Benign positional vertigo is one of the few neurologic entities the emergency physician can cure at the patient's bedside by performing a series of simple and safe head-hanging maneuvers.

For further information, see Benign Positional Vertigo in the Neurology volume.

Pathophysiology

Benign positional vertigo (BPV) is caused by calcium carbonate particles called otoliths (or otoconia) that are inappropriately displaced into the semicircular canals of the vestibular labyrinth of the inner ear. These otoliths are normally attached to hair cells on a membrane inside the utricle and saccule. Because the otoliths are denser than the surrounding endolymph, changes in vertical head movement causes the otoliths to tilt the hair cells, which sends a signal informing the brain that the head is tilting up or down.

The utricle is connected to the 3 semicircular canals. The otoliths may become displaced from the utricle by aging, head trauma, or labyrinthine disease. When this occurs, the otoliths have the potential to enter the semicircular canals. When they do, they usually enter the posterior semicircular canal because this is the most dependent (inferior) of the 3 canals, and so gravitational forces will result in most otoliths entering the posterior canal.

Anatomy of the semicircular canals. Anatomy of the semicircular canals.

According to the canalolithiasis theory (the most widely accepted theory describing the pathophysiology of benign positional vertigo), the otoliths are free-floating within the semicircular canal. Changing head position causes the misplaced otoliths to continue to move through the canal after head movement has stopped. As the otoliths move, endolymph moves along with them and this stimulates the hair cells of the cupula of the affected semicircular canal, sending a signal to the brain that the head is turning when it is not.  This results in the sensation of vertigo. When the otoliths stop moving, the endolymph also stops moving and the hair cells return to their baseline position, thus terminating the vertigo and nystagmus. Reversing the head maneuver causes the particles to move in the opposite direction, producing nystagmus in the same axis but reversed in direction of rotation. The patient may describe that the room is now spinning in the opposite direction. When repeating the head maneuvers, the otoliths tend to become dispersed and thus are progressively less effective in producing the vertigo and nystagmus (hence, the concept of fatigability).

Epidemiology

Frequency

United States

The incidence of benign positional vertigo (BPV) is 64 cases per 100,000 population per year (conservative estimate).[1]

International

One study in Japan found an incidence of 11 cases per 100,000 population per year, but patients were counted only if examined by a subspecialist or at a referral center.

Mortality/Morbidity

The B of BPV stands for benign and designates that the cause of the vertigo is peripheral to the brainstem and, hence, likely to be benign. However, BPV can be severely incapacitating to the patient.

Sex

Women are affected twice as often as men.

Age

BPV, in general, is a disease of elderly persons, although onset can occur at any age. Several large studies show an average age of onset in the mid 50s. Vertigo in young patients is more likely to be caused by labyrinthitis (associated with hearing loss) or vestibular neuronitis (normal hearing).

 

Presentation

History

When asked about their dizziness, patients with benign positional vertigo (BPV) characteristically describe that the room or world is spinning. However, other descriptions, such as rocking, tilting, somersaulting, and the like, are also possible. All that matters is that an illusion of motion is caused by a misperception of a stimulus (the otoliths that have inappropriately entered one of the semicircular canals). Diagnosis of BPV is based on a characteristic history and a positive Hallpike test.

Episodic vertigo occurs after head movements, often in association with the following: 

  • Rolling over in bed

  • Lying down

  • Sitting up

  • Leaning forward

  • Turning the head in a horizontal plane

Symptoms of BPV are usually worse in the morning (the otoliths are more likely to clump together as the patient sleeps and exert a greater effect when the patient gets up in the morning) and mitigate as the day progresses (the otoliths become more dispersed with head movement).

Nausea is typically present (vomiting is less common).

A history of head trauma may be present, especially in young patients with BPV. The head trauma may dislodge the otoliths off the hair cells within the utricle, allowing them the opportunity to enter the semicircular canals.

Eliciting that the individual episodes of vertigo in BPV last for seconds at a time is important. Patients may describe that they are having continuous vertigo, when in reality, they are having repeated episodes (with each episode typically lasting seconds or less than a minute). Patients with vestibular neuritis and labyrinthitis have continuous vertigo, often for hours to days.

During the interview, if patient states that the "room is spinning" while the patient's head is still and prior to any manipulative tests, then it is highly unlikely that the patient has BPV because the vertigo in BPV lasts for seconds at a time and occurs only after head movement.

Physical

In addition to the patient's history, a diagnosis of benign positional vertigo (BPV) is confirmed by a positive Hallpike test (see video below).[2, 3]

Hallpike test. In this example, the right posterior semicircular canal is being tested. Note that the head extends over the edge of the gurney. The thumb can be used to help keep the eyelids open since noting the direction of the nystagmus is important.

In this test, the patient is placed in the head-hanging position after turning the head 45 degrees to one side. After a short delay of a few seconds, nystagmus and reproduction of the vertigo occurs and typically resolves within 30-60 seconds. In general, the Hallpike test will be positive on one side (the side with the otoliths in the posterior semicircular canal) and negative on the other side. If the test is positive on both sides, this suggests bilateral posterior semicircular canal involvement (rare), horizontal semicircular canal involvement, or some other entity. The neurologic examination is otherwise unremarkable.

The direction of nystagmus (an involuntary rhythmic oscillation of the eyes) is described in terms of the corrective fast-phase component.It is usually torsional or rotatory. In the head-hanging position, the fast phase should beat toward the forehead (upbeat) and in the same direction as the affected side (ipsilateral). Although some describe the fast phase in terms of being clockwise or counterclockwise, most experts avoid this terminology because it can be unclear if the clock is being viewed from the patient's or physician's perspective.

Nystagmus usually occurs within 10 seconds after positioning but may present as late as 40 seconds. Hence, if the history is classic, observe the patient for at least 40 seconds while he or she is in the head-hanging position during the Hallpike test.

The duration of the observed nystagmus varies from a few seconds to a minute and parallels the sensation of vertigo.

Both symptoms and nystagmus may decrease if the patient is repeatedly placed into the provoking position due to dispersion of the otoliths.

Note: If the patient has a classic history of BPV (after a short delay, the room spins, but then revolves in 20–30 seconds, and then the rooms spins in the opposite direction when he or she sits back up) but no nystagmus is seen during the Hallpike test, most experts would agree to consider the patient to have BPV because nystagmus may be blocked by fixation suppression, in which the eyes involuntary fixate on an object and prevent the visualization of nystagmus. If Frenzel lenses are available (thick lenses that prevent focusing by the eyes) then they should be used, though most EDs do not carry them (see Treatment).

One study showed that treating such patients (classic history without nystagmus) with the Epley maneuver is still effective. Again, these patients should have a classic history and be symptomatic during Hallpike testing.

Perform the Hallpike test as follows (Caution: For patients with cervical spondylosis, it may not be advisable to extend the neck. However, because having the head dependent is important, the same effect can be achieved if the gurney is placed in the Trendelenburg position for such patients).

First, warn the patient that symptoms of vertigo will likely be reproduced but will resolve after a few seconds.

Seat the patient close enough to the end of the gurney so that when he or she lies supine, the head can extend backward an additional 30-45°.

Instruct the patient to keep his or her eyes open because you want to observe the direction of the nystagmus. The examiner may need to use his thumb to hold the eyelid open because patients may involuntarily close their eyes even when instructed to keep them open.

To test the left posterior canal, follow these steps:

  • Turn the patient's head 45° to the left. This position orients the head such that the left posterior semicircular canal is going to be in the same plane as the upcoming head movement (next step). This is the most provocative way to move the otoliths (if they are indeed in the posterior semicircular canal) which will result in a positive test.

  • With your hands on either side of the patient's head, lay the patient down until the head is dependent (hanging over the edge of the gurney). Note that this step does not need to be performed rapidly.

  • Check for reproduction of symptoms and nystagmus. In most cases, the fast phase of the nystagmus should be upbeat (toward the forehead) and ipsilateral (in this example, toward the patient's left).

  • Return the patient to the upright position. Nystagmus may be observed in the opposite direction, and the patient may describe that the world is spinning in the opposite direction.

To test the right posterior canal, repeat the Hallpike test with the head turned 45° to the right side. In general, if the patient has BPV, only one side should test positive during the Hallpike test. Although having bilateral posterior semicircular canal BPV is possible, it is unlikely and should suggest horizontal canal involvement, vestibular neuritis/labyrinthitis, or a central cause.

Note that many patients experience mild dizziness when being brought up from the head-hanging position to the sitting position. It is important not to confuse this dizziness (which is more lightheaded in character) with true vertigo.

If the patient's head cannot be extended over the edge of the gurney, 2 additional options exist. The first is to place the patient in the Trendelenburg position if a gurney that allows this position is available. The other alternative is to use the side-lying test; the patient sits with his or her legs over one side of the gurney. To test the left posterior semicircular canal, turn the patient's head 90° to the opposite side (in this case, the right side). Then, lay the patient on his or her left side. By turning the patient's head to the right, the left posterior semicircular canal is aligned in the same plane as the sideways movement. As in the Hallpike test, this will allow the greatest chance for otoliths to move if they are indeed located in the posterior semicircular canal.

The neurologic examination findings should be otherwise normal; if not, strongly consider alternative diagnoses.

Causes

Several disorders affecting the peripheral vestibular system may precede the onset of benign positional vertigo (BPV).

  • Idiopathic (50-60%)

  • Infection (viral neuronitis)

  • Head trauma, especially in younger patients

  • Degeneration of the peripheral end organ

  • Surgical damage to the labyrinth

 

DDx

Diagnostic Considerations

Acoustic schwannoma

Chronic otomastoiditis

Congenital malformation (inner ear)

Medications (alcohol, phenytoin, diuretics, salicylates, quinidine, quinine, barbiturates, antibiotics)

Otosclerosis

Ototoxicity

Polyarteritis nodosa

Posttraumatic injuries

Posterior fossa neurosurgery

Postsurgery (general)

Postsurgery (ear)

Vertebrobasilar insufficiency

Differential Diagnoses

 

Workup

Laboratory Studies

No pathognomonic laboratory test for benign positional vertigo (BPV) exists. Laboratory tests may be performed to rule out other pathology.

Imaging Studies

Currently, no imaging study can demonstrate the presence of otoliths.

Head CT scanning or MRI is indicated if the diagnosis is in doubt.

Other Tests

Although most patients with benign positional vertigo (BPV) have posterior semicircular canal involvement, some patients have horizontal canal involvement. This canal should be suspected if the patient has bilateral symptoms during the Hallpike test. Use the Roll test to formally diagnose horizontal canal BPV, and use the bar-b-que treatment to treat horizontal canal BPV.

Roll test

Have the patient lie in the supine position on the gurney. Unlike the Hallpike test, the head does not need to hang over the edge of the gurney.

Turn the patient's head 90° to one side. The patient should experience a reproduction of symptoms and the presence of horizontal nystagmus. The fast phase should beat toward the earth (geotropic).

Now, turn the patient's head 180° (or 90° to the opposite side). The patient should again experience a reproduction of symptoms and the presence of horizontal nystagmus. The fast phase again beats toward the earth (note that it has changed direction). This is known as direction-changing nystagmus (nystagmus that changes direction based on turning the head) and is different from gaze-evoked nystagmus (which is nystagmus that changes direction depending on where the patient is looking, as in Dilantin toxicity).

Note that no matter which way the head is turned, the patient will develop nystagmus and have reproduction of symptoms; however, one side will be much more symptomatic (and demonstrate stronger nystagmus) than the other side. This is the involved side. Like posterior canal BPV, it is important to know which side is involved since that dictates the starting position for the curative maneuver.

A positive Roll test should be treated with the bar-b-que treatment (see Treatment and the video below). The head is rotated away from the involved side. 

Bar-b-que maneuver. This maneuver is used to treat horizontal canal benign positional vertigo. In this example, the right horizontal canal is being treated. Each position should be held at least 20-30 seconds.

Head-thrust test (head-impulse test)

The head-thrust test is used to diagnose vestibular neuritis and labyrinthitis.

In this test, the patient is told to look at the examiner's nose. The examiner places both his or her hands on the patient's head and rapidly turns it approximately 10–15° to one side. If the vestibular apparatus is functioning properly, the patient will be able to maintain his or her focus on the examiner's nose. If the vestibular apparatus is not working properly, the patient's eyes will deviate to the side and then quickly jerk back to view the examiner's nose. This jerking eye movement is called a saccade and indicates a positive head-thrust test. As a general rule, a positive head-thrust test rules in a peripheral (and hence benign) cause of vertigo. There are reported cases, however, of positive head-thrust tests in central causes of vertigo. In the author's opinion, this test should not be used liberally and only performed when indicated because a negative head-thrust test is more concerning for a central cause of vertigo.

Procedures

The Hallpike test, along with the patient's history, confirms the diagnosis of BPV. See Physical for details of this procedure.

The modified Epley maneuver is used to treat posterior canal BPV (see Treatment as well as the video below for a demonstration).[4]

Epley maneuver. In this example, the left posterior semicircular canal is being treated. In this clip, the maneuvers are performed quickly. In a real patient, each position should be held for at least 30 seconds or until resolution of the nystagmus and vertigo.
 

Treatment

Emergency Department Care

If the history and physical examination are typical, no further evaluation is necessary, and the emergency physician may proceed with the modified Epley maneuver described below (see the video below).

Epley maneuver. In this example, the left posterior semicircular canal is being treated. In this clip, the maneuvers are performed quickly. In a real patient, each position should be held for at least 30 seconds or until resolution of the nystagmus and vertigo.

If the history and physical examination findings are atypical, consider other causes of positional vertigo, which may occur with tumor or infarcts in the posterior fossa.

Contraindications to performing the Epley maneuver include ongoing CNS disease (ie, stroke or transient ischemic attack [TIA]), unstable heart disease, severe neck disease (eg, rheumatoid arthritis) or history of cervical spine fracture or surgery, carotid bruit on examination indicating carotid stenosis, or body habitus preventing performance of the maneuver.

Further information on diagnosis and treatment guidelines and recommendations are available from the American Academy of Neurology and the American Academy of Otolaryngology-Head and Neck Surgery Foundation.[2, 5]

The goal of the Epley maneuver is to move the otoliths out of the posterior semicircular canal and back into the utricle where they belong.

The success rate of the Epley maneuver is approximately 80%. When it fails, it is the author's experience that it is either being incorrectly applied to patients with vestibular neuritis or labyrinthitis, or that the patient raised his/her head too high in the 3rd part of the Epley maneuver, in which the patient rolls onto the side and looks towards the ground.

Epley maneuver, general guidelines

The head must be in the dependent (head-hanging) position for this maneuver to work. If the patient does not tolerate this position, put the gurney in the Trendelenburg position to simulate this head-hanging position.[6]

Maintain each position until the symptoms and nystagmus have disappeared or for at least 30 seconds.

If the patient cannot tolerate the maneuver because of vomiting or severity of the vertigo, premedicate with a vestibular sedative, such as 4 mg IV ondansetron (Zofran).

Epley maneuver steps

Have the patient sit upright on the gurney with the head turned 45° to the affected side. Recall that the affected side was predetermined by using the Hallpike test. Make sure the patient is sitting far enough back in the gurney so that the head will hang over the edge of the gurney when the patient is laid back. Make sure the guardrail on the opposite side has been lowered (the patient will eventually sit up so his or her legs overhang the edge of the gurney). See the image below.

Epley maneuver. Move the patient back in the gurne Epley maneuver. Move the patient back in the gurney such that when he lies down, his or her head will hang over the edge of the gurney. Emphasize to the patient to keep his or her eyes open during each position so that nystagmus can be observed. Lower the guardrails of the gurney on the opposite side from which the patient's head is turned.

Place your hands on either side of the patient's head and guide the patient down with the head dependent (as in the Hallpike test). See the image below.

Epley maneuver. Turn the patient's head 45° to the Epley maneuver. Turn the patient's head 45° to the side that had the most prominent symptoms during the Hallpike test. In this example, the patient's head is turned 45° to the left. With both hands holding the patient's head, gently lay the patient down in the supine position with the head hanging over the edge of the bed. Note: Each maneuver does not need to be performed rapidly. The Epley maneuver is positional, not positioning.

Rotate the head 90° to the opposite side with the patient's face upward and be sure to maintain the head-dependent position (head is hanging over the edge of the gurney).

Ask the patient to roll onto his or her side while holding the head in this position and then rotate the head so that it is facing downward (tell the patient to look to the ground). See the images below.

Epley maneuver. Ask the patient to turn onto his o Epley maneuver. Ask the patient to turn onto his or her shoulder.
Epley maneuver. Guide the patient's head down so t Epley maneuver. Guide the patient's head down so that he or she is looking at the ground. Again, wait for at least 30 seconds.

Raise the patient to a sitting position while maintaining head rotation (This author finds that sitting the patient up so that he or she is sitting with his or her legs hanging over the edge of the gurney is easier. This is why the side guardrails need to be lowered before the procedure is started). See the images below.

Epley maneuver. The patient's head needs to be reg Epley maneuver. The patient's head needs to be regripped again. Then, the patient needs to sit up with the legs hanging over the side of the gurney (which is why the guardrails need to be lowered before the start of the procedure).
Epley maneuver. The patient is now sitting upright Epley maneuver. The patient is now sitting upright.

Simultaneously rotate the head to a central position and move it 45° forward.

The Semont maneuver (liberatory maneuver)

This maneuver is primarily used in Europe. Although it can be used to treat classic posterior canal BPV, in the United States, it is usually reserved to treat the cupulolithiasis form of BPV (where the otoliths are not free-floating but instead are attached to the cupula of the posterior semicircular canal). Because of its somewhat violent nature (and the fact that most patients with BPV are elderly), the author does not advocate its use but includes it to be complete.

As in the side-lying test, the patient sits on the edge of the gurney with the head turned opposite to the involved side. The patient is brought rapidly down onto his or her side (this serves to dislodge the otoliths off the cupula). The patient is then rapidly brought to the other side, maintaining the head in the same position (so the patient's face will be facing the gurney). The patient is then brought to the original sitting position. See the video below.

Semont maneuver. Generally reserved for the cupulolithiasis form of benign positional vertigo, in which the otoliths are attached to the cupula of the semicircular canal. This maneuver has to be performed rapidly to be effective, and it is not recommended in elderly persons. In this example, the right posterior semicircular canal is being treated.

Consultations

Neurologic consultation is indicated for cases of positional vertigo and nystagmus that do not satisfy criteria for BPV. For example, downbeat (fast phase beating towards the feet) nystagmus is more likely to indicate a central cause of vertigo as opposed to peripheral vertigo caused by anterior semicircular canal involvement, the latter of which is extremely rare.

 

Medication

Medication Summary

Medical treatment for benign positional vertigo (BPV) is generally ineffective but may be used to lessen the symptoms.[5] The natural history of BPV is to resolve with time as most otoliths eventually dissolve while in the semicircular canals.

The use of vestibular suppressants is based on the sensory conflict theory, in which sensory input is compared from different systems, and if a conflict exists, then vertigo, nausea, and vomiting result. Over time, habituation occurs. Several main neurotransmitters mediate these functions: GABA, acetylcholine, and histamine/serotonin.

Antiemetic Agents

Class Summary

The antihistaminic antiemetics block the emetic response. For patients with severe vertigo or vomiting, intravenous promethazine (Phenergan) used to be the drug of choice; however, this medication recently received a Black Box Warning from the FDA and is now only recommended to be given intramuscularly. Prochlorperazine (Compazine) is an alternative antiemetic. Meclizine is given orally and does not work fast enough to be effective acutely. Most antiemetics have anticholinergic activity as well.

Promethazine (Phenergan, Anergan, Prorex)

Antidopaminergic agent used to treat emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to brainstem reticular system. Also has cross reactivity with the cholinergic receptors.

Meclizine (Antivert, Antrizine, Dramamine)

Decreases excitability of middle ear labyrinth and blocks conduction in middle ear vestibular-cerebellar pathways. These effects are associated with relief of nausea and vomiting.

Scopolamine (Isopto, Scopace Tablet)

Blocks action of acetylcholine at parasympathetic sites in the smooth muscle, secretory glands, and CNS. Antagonizes histamine and serotonin action.

Transdermal scopolamine may be most effective agent for motion sickness. Use in the treatment of BPV is limited by slow onset of action.

Dimenhydrinate (Dimetabs, Dramamine)

Mixture of 1:1 salt consisting of 8-chlorotheophylline and diphenhydramine. Believed to be useful, particularly in treatment of vertigo. Diminishes vestibular stimulation and depresses labyrinthine function through central anticholinergic effects. However, prolonged treatment may decrease rate of recovery of vestibular injuries.

Antiemetics, Selective 5-HT3 Antagonist

Class Summary

These agents are an option for treating emesis associated with BPV. They may be administered IV, IM, or orally, including an orally disintegrating tablet and oral soluble film.

Ondansetron (Zofran, Zofran ODT, Zuplenz)

Ondansetron selective 5-HT3 receptor antagonist; binds to 5-HT3 receptors both in periphery and in CNS, with primary effects in GI tract. It has no effect on dopamine receptors and therefore does not cause extrapyramidal symptoms.

Benzodiazepines

Class Summary

These agents block the GABA receptors and serve as the "brakes" to the system. Although they can be used acutely in the ED, they are not recommended for long-term use because they interfere with the process of vestibular rehabilitation.

Lorazepam (Ativan)

Sedative hypnotic in benzodiazepine class that has short time to onset and relatively long half-life. Depresses all levels of CNS, including limbic and reticular formation, probably through increased action of GABA, a major inhibitory neurotransmitter.

 

Follow-up

Further Outpatient Care

Head exercise therapy (positional exercises of Brandt and Daroff) that promotes central accommodation may be helpful for BPV, although most patients have difficulty tolerating these maneuvers. The patient can perform the following therapy:

  • Sit on the edge of the bed near the middle, with legs hanging down.

  • Turn the head 45° to the right side. Quickly lie down on the left side, with the head still turned, and touch the bed with a portion of the head behind the ear.

  • Maintain this position and every subsequent position for about 30 seconds.

  • Sit up again.

  • Quickly lie down to the right side after turning head 45° toward the left side.

  • Sit up again.

  • Do 6-10 repetitions, 3 times per day.

  • If the patient becomes confused about the direction to turn his or her head, tell the patient his or her nose should always point toward the ceiling.

Further Inpatient Care

Patients with persistent vomiting or intractable vertigo may require admission for hydration and vestibular suppressant medication.

Surgical elimination of posterior canal function is restricted to rare cases of long-standing refractory benign positional vertigo (BPV).

Inpatient & Outpatient Medications

Meclizine is the most common outpatient medication. This medication is indicated for vertigo but should not be given for other categories of dizziness (near-syncope, dysequilibrium, or lightheadedness).

Deterrence/Prevention

Avoid provocative movements and limit activities.

Complications

No complications (eg, neck injury, vertebral dissection) other than vomiting have been reported from the use of the Epley maneuver.

Prognosis

Benign positional vertigo (BPV) tends to resolve spontaneously after several days or weeks. An Italian researcher removed the otoliths from an animal, placed them in a Petri dish full of endolymph, and noted that the otoliths dissolved in approximately 100 hours.

Patients may experience recurrences months or years later (if the otoliths got out once, they can do it again).

Variants range from a single, short-lived episode to decades of vertigo with only short remissions.

A study by Kim et al assessed patients who were discharged home from the ED with a diagnosis of isolated dizziness or vertigo and determined that stroke occurs in less than 1 in 500 patients within the first month.[7] Cerebrovascular risk factors should be considered for individual patients.

Patient Education

See the list below:

  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Benign Positional Vertigo.