Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo[1]. This disease has the most effective treatment option among vestibular disorders[2]. BPPV is caused by a change in the position of the individual and it has been reported that up to 90% of positioning vertigo/nystagmus are related to BPPV and in 85% of BPPV cases, involvement of posterior canal is seen [3, 4]. The onset of BPPV is usually in the fifth and seventh decades of life [1]. In Tan study (2018) on 500 BPPV patients, the age of disease onset was 56 years-old and it was more prevalent in women [5]. This disease is probably the most common diagnosis in vertigo clinics and is the cause of vertigo in 20-40% of all cases with vertigo [6, 7]. Moreover, it is a comorbid condition in menieres disease, vestibular neuritis and vestibular migraine. The main symptom of BPPV is vertigo that is caused by changes in the head position of the patient in relation to the gravity [8]. Episodes of vertigo in BPPV last 10-20 seconds and occasionally last up to one minute [9]. Most of BPPV patients report that they feel a transient vertigo when they are lying, turning in bed, bending or picking something up from cabinet. These patients do not have any symptom of vertigo when they are not moving. Other problems that are reported with BPPV include disequilibrium which happens in few hours to few days after the vertigo attack and other vague feelings such as light-headedness and feeling of being suspended in the air [10].

Schucknecht, for the first time, described the pathophysiology of BPPV and in 1969 introduced the cupulolithiasis theory based on pathologic studies[11]. In 1979, Hall introduced canalolithiasis theory which was a basis for canalith repositioning maneuvers for treatment of BPPV [12, 13]. In this disease, each of lateral, superior and posterior canals could be involved and type of BPPV is diagnosed based on nystagmus patterns in Dix-Hallpike and other diagnostic maneuvers. Posterior semicircular canal (right side) is usually more affected than lateral and superior canals [1, 14].

The first mention of the disease was by Shakespeare in Romeo and Juliet in Act I, Scene II[15]. In medical articles, the first description of BPPV was by Adler[16] and Then Barany[17] which believed that this disease is the consequence of otolith organs dysfunction. In 1952, Margaret Dix and Charles Hallpike developed a positional test for BPPV[1].

BPPV can be caused by different disorders which damage inner ear and lead to detachment of otolith from utricular macula. However, in most cases, the cause of BPPV is unknown [8]. The primary or idiopathic BPPV is a kind of BPPV which is seen alone is and includes almost 50-70% of BPPV cases. Secondary BPPV is the result of other causes, and the most common cause is head trauma (7-17% of BPPV cases). Other causes of secondary BPPV are viral neurolabiryntitis or vestibular neuronit (up to 15% of BPPV cases), Menieres disease (5%), migraine, otologic or non-otologic surgeries and long-term bed rest [6]. In sum, each inner ear disease which detach otoconia but does not totally damage semicircular canal function can lead to secondary BPPV. Recurrences of endolymphatic hydrops cause macular fibrosis and detachment of otoconia. It has been shown that repositioning maneuvers are a better treatment option for idiopathic BPPV patients [18].

Dix-Hallpike Test

Dix-Hallpike positioning test is designed to stimulate subjective vertigo and nystagmus created by BPPV. Symptoms of posterior canal BPPV are sudden onset and short term vertigo and nystagmus which are caused by changing head position of patient. Dix-Hallpike maneuver only assesses posterior and anterior canal BPPV. For diagnosis of anterior canal BPPV, other maneuvers such as roll maneuver should be used [19].


Medication does not have a significant role in treatment of BPPV, and is prescribed only in the early stages in which dizziness may not be tolerated. In fact, the main effective treatment options of BPPV are rehabilitation maneuvers which in more than 70% of cases lead to complete recovery. It is believed that repositioning maneuvers treat BPPV by moving the otoconia particles from the semicircular canal to the vestibular system, where they are re-absorbed [7]. The number of maneuvers required to treat BPPV range from one to three (with an average of 1.5) maneuvers. However, there are some cases which need 10 or more than 10 maneuvers [20].

Initially, BPPV was treated with vestibular suppressor drugs and restriction of position change in order to prevent vertigo attacks. This type of treatment prolonged the course of the disease. In 1980, Brandt-Daroff exercises were introduced for treatment of this disease in which, patients should perform active exercises. These exercises are known as habituation exercises because patient will be taught to move in to exciting position until there is no symptom. The purpose of these exercises is diffusing the particles of the otoconia into the affected canal, and not necessarily the outflow of these particles from the canal. As the result of these exercises, vertigo and nystagmus subsides. It has been shown that using these exercises, the duration of BPPV treatment decreased to 3-14 days and after this time period, 98% of patients did not have any symptoms. However, most patients do not perform Brandt-Daroff exercises because they cannot tolerate symptoms. BPPV patients were not treated effectively until the late 1980s and early 1990s in which repositioning maneuvers were introduced. In 1998, Semont Liberatory maneuver was introduced. In this maneuver, patient should not move for 2-3 minutes. After 1-2 maneuvers, 73-93% of patients would not have any symptoms. John Epley’s therapeutic maneuver was introduced in 1992. In this maneuver, patient should remain stable for 2-4 minutes. It has been reported that 60-90% of patients were effectively treated with this maneuver. Although a similar success rate has been reported for different types of CRM, one study showed that the effect of the epley maneuver is greater than that of Samont maneuver [21]. In a study, it was shown that home repositioning maneuvers reduce the likelihood of BPPV recurrence[22].

Factors such as depression and anxiety reduce the success of repositioning maneuvers and also increase the likelihood of recurrence of BPPV. In women, the same effect has been observed [23].


  1. Hornibrook, J., Benign Paroxysmal Positional Vertigo (BPPV): History, Pathophysiology, Office Treatment and Future Directions. Int J Otolaryngol, 2011. 2011: p. 835671.
  2. von Brevern, M., Benign paroxysmal positional vertigo. Semin Neurol, 2013. 33(3): p. 204-11.
  3. Hotson, J.R. and R.W. Baloh, Acute vestibular syndrome. N Engl J Med, 1998. 339(10): p. 680-5.
  4. Furman, J.M. and S.P. Cass, Benign paroxysmal positional vertigo. N Engl J Med, 1999. 341(21): p. 1590-6.
  5. Tan, F., C. Bartels, and R.M. Walsh, Our experience with 500 patients with benign paroxysmal positional vertigo: Reexploring aetiology and reevaluating MRI investigation. Auris Nasus Larynx, 2018. 45(2): p. 248-253.
  6. Fife, T.D., 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. 70(22): p. 2067-74.
  7. von Brevern, M., et al., Benign paroxysmal positional vertigo predominantly affects the right labyrinth. J Neurol Neurosurg Psychiatry, 2004. 75(10): p. 1487-8.
  8. Lee SH, K.J., Benign Paroxysmal Positional Vertigo. J Clin Neurol, 2010: p. 6.
  9. Fife, T.D. and M. von Brevern, Benign Paroxysmal Positional Vertigo in the Acute Care Setting. Neurol Clin, 2015. 33(3): p. 601-17, viii-ix.
  10. Kollen, L., et al., Benign paroxysmal positional vertigo is a common cause of dizziness and unsteadiness in a large population of 75-year-olds. Aging Clin Exp Res, 2012. 24(4): p. 317-23.
  11. Schuknecht, H.F., Cupulolithiasis. Arch Otolaryngol, 1969. 90(6): p. 765-78.
  12. Semont, A., G. Freyss, and E. Vitte, Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol, 1988. 42: p. 290-3.
  13. Epley, J.M., The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg, 1992. 107(3): p. 399-404.
  14. Silva, C., A.M. Amorim, and A. Paiva, Benign paroxysmal positional vertigo–a review of 101 cases. Acta Otorrinolaringol Esp, 2015. 66(4): p. 205-9.
  15. Kaga, K., “Personal communication: historical discovery of vestibular peripheral system and new insights on bilateral vestibular neuropathy in patients,” Proceedings of the Barany Society XXIII Congress, Paris, France,. July 2004.
  16. Adler, D., Ubeden ‘einseitigen Drehschwindel. Dtsch Z Nervenheilkd, 1897: p. 18.
  17. Barany, R., Diagnose von krankheitserch-eingungen im mereiche de otolithenapparates. Acta Otolaryngol, 1921. 2: p. 5.
  18. Riga, M., et al., Inner ear disease and benign paroxysmal positional vertigo: a critical review of incidence, clinical characteristics, and management. Int J Otolaryngol, 2011. 2011: p. 709469.
  19. Kim, J.S. and D.S. Zee, Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med, 2014. 370(12): p. 1138-47.
  20. Perez, P., et al., Recurrence of benign paroxysmal positional vertigo. Otol Neurotol, 2012. 33(3): p. 437-43.
  21. Lee, J.D., et al., A multicenter randomized double-blind study: comparison of the Epley, Semont, and sham maneuvers for the treatment of posterior canal benign paroxysmal positional vertigo. Audiol Neurootol, 2014. 19(5): p. 336-41.
  22. Ismail, E.I., A.E. Morgan, and M.M. Abdeltawwab, Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx, 2018.
  23. Wei, W., et al., Presence of Anxiety and Depression Symptoms Affects the First Time Treatment Efficacy and Recurrence of Benign Paroxysmal Positional Vertigo. Front Neurol, 2018. 9: p. 178.


Dizziness is usually defined in dictionaries as the sense of spinning and imbalance or as impairment in perception of balance and spatial stability.
It must be noted that dizziness is a nonspecific word and refers to impairments such as vertigo (40-45%), disequilibrium (16%), presyncope (14%) and light-headedness (10%). Moreover, other ambiguous feelings which patients may experience are some of the other subtypes of dizziness.
Although dizziness has been reported in children too, its prevalence increases in older ages. Dizziness in women is 2-3 times more than men.
Dizziness usually doesn’t lead to serious problems for patients and sometimes recovers spontaneously. However, some of the life-threatening disorders result in dizziness which makes the immediate intervention necessary. Neuhauser (2009) reported that in 0/7% of patients who present to the emergency room, stroke is the cause of dizziness. Furthermore, cardiovascular disorders are other important causes of dizziness.
Contrary to the popular opinion, dizziness and vertigo are not identical symptoms. Therefore, in history taking of a dizzy patient, it should be exactly recognized that what is the chief complaint of the patient and how their dizziness is. This issue can negatively affect diagnosis and treatment of the patient.
The main sensory systems which are responsible for creation and maintenance of balance include vision, proprioception and vestibular system in the inner ear. We should take into consideration that the degree of contribution of each these organs changes in stable and unstable surfaces. Moreover, different balance disorders change this sensory weighting. On the other hand, sometimes professionals can improve a specific sensory system function through vestibular rehabilitation exercises to substitute the impaired balance system. Overall, coordination and health of all organs of the body such as central nervous system and even psychological status is required to maintain balance.
A highly important and sometimes challenging subject regarding dizziness is the correct differential diagnosis of its underlying disorders. This issue is due to this fact that dizziness, vertigo and balance problems are usually accompanied by severe and debilitating symptoms and disorders. Hence, vertigo and balance professionals must be completely aware of the factors causing dizziness and key issues that are helpful in differential diagnosis of dizziness causes.