What is Benign Paroxysmal Positional Vertigo (BPPV)?

Vertigo is a topic that is currently gaining much attention in the world of medicine. Benign Paroxysmal Positional Vertigo is no stranger to Doctor’s offices or ER’s as it is the most common occurring condition in neuro-otological practice and is accountable for an estimated 17% of all vertigo cases. BPPV is characterized by temporary vertigo attacks which are caused by changing the position of the head in relation to gravity. A slight movement of the head or even a nod is enough to trigger an attack. Another feature of an attack of benign paroxysmal positional vertigo is paroxysmal nystagmus, which is a repetitive back and forth movement of the eyes. [1][2]

Attacks of BPPV may occur suddenly and without warning. Even though these attacks last for only a few seconds, they can be very distressing to the patient. Imagine that by just turning your head, you become so dizzy that you can’t stand straight!
Old and young, people of all ages are affected by BPPV although it is known to affect people between the ages of 50 and 70 more commonly. This condition has a female dominancy as women are more likely to be affected by BPPV than men. Episodes of BPPV may affect someone more than once and has an estimated lifetime occurrence of 2.4%. It has, however, been speculated by experts that this percentage should be higher as many people do not report having had such an attack because the symptoms cleared up spontaneously. [1][3]

So I’m not an expert… how is BPPV caused?

BPPV is caused by disturbances of the inner ear canal from where balance is controlled. In order to simplify the pathological mechanisms, here is a short anatomical description of the inner ear canals.

On both sides of the human skull are the temporal bones which contain bony labyrinths. These bony labyrinths are formed by tubes and cavities which house the membranous labyrinth and its surrounding perilymph. The canals are known as the semicircular canals and are filled with endolymph. The three semicircular canals lie perpendicular to each other. The ampullar crest is an elevation in the ampulla (anterior dilation) of each semicircular canal. Nerve fiber patches, originating from fibers of the vestibular nerve, are found in the ampullar crest. These nerve fibers project into the gel-like cupula. [1][2][3][4]

Differences in the density of the labyrinth endolymph and cupulae are what cause the symptoms of BPPV.

Degenerative particles build up and either drift around in the endolymph or attach to the cupulae. This changes the balance of the density of the cupulae-endolymph system. The orientation line, in relation to gravity, of the semicircular canals changes when you change the position of your head. The particles dislocate and become detached and this promotes the distorted stimulation of the ampullar crest. This causes sensory conflict that leads to improper balance and nystagmus. [1][2][3]

How is BPPV diagnosed?

BPPV is diagnosed by a patient’s account of vertigo symptoms that come and go. If you experience these symptoms, it is very important for you to provide the practitioner with as much information as possible about your experience. The doctor will examine the eyes for ‘to and fro’ movements using the ‘Hallpike maneuver’. During this maneuver you have to keep your eyes open. The health practitioner swings your head rapidly through 120 degrees so that it hangs over the edge of the exam table. This is done with your right ear facing downwards first and is followed by your left ear facing downward. The practitioner will then look to see if nystagmus is present and if it is accompanied by vertigo. [1][2]

At Dizziness and Balance Clinic, we take a 3 step assessment approach to properly evaluate the cause of BPPV. This includes

  1. Neurological testing with a computerized balance test and eye movement recording with infrared goggles
  2. Physical exam of the neck, jaw and other spinal structures that can have an influence on your ability to remain balanced and stable
  3. Metabolic assessment looking at your diet and other lifestyle factors

BPPV is classified as primary or secondary, where in primary BPPV the cause is not known (idiopathic). Secondary causes include head trauma, inner ear surgery, vestibular neuritis, otitis media (middle ear infection) and Ménière’s disease. [3]

Living with BPPV

People who suffer from Benign Paroxysmal Positional Vertigo are not only plagued by the symptoms of this debilitating condition, but also suffer from the effects it has on their lives. [5]

The onset of an attack is usually very sudden and without warning. It may take one slight movement of the head to trigger such an attack. Dizziness suddenly ensues and the person becomes disoriented and severely off balance. The fear of having an episode is enough to petrify the bravest of heart.

Notwithstanding the dreadful symptoms of an attack, Benign Paroxysmal Positional Vertigo can adversely affect someone socially and financially.

BPPV is a sporadic condition and because of this, it may be difficult to diagnose. This implies that much money and time is spent in the process of reaching a diagnosis. It can become frustrating and incapacitate a person financially. [3]

Another financial struggle is the fact that BPPV can debilitate someone to the point that it may become hard to keep a job. [6]

The effects of BPPV are not only troublesome to the patients themselves, but also to the people around them. This may be a cause of conflict in personal relationships and therefore devastating consequences may follow for a person’s social life.

It is clear to see that BPPV is no spring breeze. It can come along suddenly and have detrimental outcomes on someone’s life.

Dizziness and Balance Clinic

Dizziness and Balance Clinic based in Sydney, led by Chiropractor Dr Carlo Rinaudo (Neuro-Rehabilitation), is a leading vestibular rehabilitation and brain-based therapy clinic for the treatment of people suffering from dizziness and balance disorders. Apart from being a premier clinic in helping people with BPPV, they also have built a strong reputation in helping people overcome the effects of concussion, whiplash, mild traumatic brain injury (mTBI), migraines and acquired brain injury (ABI).

  1. Bittar RSM, Mezzalira R, Furtado PL, Venosa AR, Sampaio ALL, De Oliveira CACP. Benign paroxysmal positional vertigo: diagnosis and treatment. International Tinnitus Journal. 2011; vol. 16(2): 135-145.
  2. Boon NA, Colledge NR, Walker BR. Davidson’s principles and practice of medicine. 20th ed. Philadelphia: Churchill Livingstone Elsevier. 2006. p. 1166, 1196.
  3. Neuhauser HK, Lempert T. Vertigo: epidemiologic aspects. Semin Neurol. 2009; vol. 29(5): 473-481.
  4. Bronstein AM. Oxford textbook of vertigo and imbalance. Oxford: Oxford University Press; 2013. p. 1-5, 198-204.
  5. Ten Voorde M, Van der Zaag-Loonen HJ, Van Leeuwen RB. Dizziness impairs health-related quality of life. Qual Life Res. 2012; 21: 961-966.
  6. Benecke H, Agus S, Kuessner D, Goodall, Strupp M. The burden and impact of vertigo: findings from the Revert patient registry. Front Neurol.