What is BPPV?

Benign Paroxysmal Positional Vertigo—commonly called BPPV—is the most frequent cause of vertigo across all age groups. Despite how intense and unsettling it can feel, BPPV is considered a mechanical inner ear condition and, in most cases, is very treatable.

What does BPPV feel like?

People with BPPV often describe:

• Sudden spinning sensations

• Vertigo triggered by rolling in bed, bending forward, or looking up

• Brief episodes lasting seconds

• Nausea or imbalance afterward

Importantly, symptoms are position-specific, which helps distinguish BPPV from other causes of dizziness.

What causes BPPV?

BPPV occurs when tiny calcium carbonate crystals (called otoconia) move into the wrong semicircular canal of the inner ear. When the head changes position, these crystals inappropriately stimulate the vestibular nerve, producing both a reflexive eye movement (nystagmus) and the strong spinning sensation. The movement of the crystals is what activates the nerve. Once the crystals settle, the movement stops and your vertigo stops. There is a less common type where the crystals are “stuck” to the cupula (the structure where the sensory hair cells are placed in the canal), which stimulates a prolonged response of vertigo and nystagmus. You will continue to get vertigo each time you are in that same position until maneuvers are performed to place the crystals back into the utricle where they belong. In some cases, patients are able to get spontaneous resolution of their BPPV during their usual every day activities.

How is BPPV treated?

BPPV is treated with specific repositioning maneuvers designed to move the crystals back where they belong. The most commonly known maneuver is the Epley maneuver. This maneuver is highly effective to treat the posterior canal BPPV variant, but will not correct horizontal canal BPPV, and is specific to what side needs to be treated. Many patients are given the Epley maneuver by their medical provider, but without testing, it is not generally known which side you are meant to treat. It will generally not harm you to do the maneuver for both sides, but you will make yourself unnecessarily dizzy if you try it on both sides. Some patients have limited neck mobility or back pain, for which other maneuvers can be done to correct the issue. It is important to see a vestibular specialist who is familiar with all of the canalith repositioning maneuvers to provide you with the most efficient and safe option for you.

If you are attempting to treat your BPPV on your own and are still having symptoms, it is most likely that you need to change how you are doing the maneuver. Possible errors could be:

• You are treating the wrong side or the wrong canal.

• You are moving too slowly through the positions. The success of the maneuver partially depends on gathering appropriate momentum to move the crystals through the fluid in the semicircular canal. (Moving too quickly through maneuvers is not recommended either to ensure your safety while performing).

• You skipped a step.

• The angle or position or your head or body are not quite right.

• You don’t have BPPV, but have another vestibular condition resulting in similar symptoms.

Prognosis is excellent:

Most patients are successful in treating their BPPV with 2-3 maneuvers. Other lucky patients only need one maneuver. Unfortunately, there are also cases where patients have persistent BPPV that requires many maneuvers to treat. The rate of recurrence of BPPV is approximately 50% of patients, meaning it is likely for you to have to do this treatment again in the future.

Research shows an association between low vitamin D levels and an increased rate of recurrence of BPPV. If you have had multiple episodes of BPPV over the years, it is worthwhile to discuss assessing your vitamin D levels with your medical providers. This is done via a blood test. If your levels are low, your medical provider may recommend a vitamin D supplement.

Do medications help?

Medications may help reduce nausea or motion sensitivity, but they do not correct the underlying cause of BPPV and are not considered definitive treatment.

The reassuring takeaway

Although BPPV can feel alarming, it is one of the most straightforward vestibular conditions to diagnose and treat. In the majority of cases, symptoms improve significantly with appropriate care.

If your dizziness feels positional, a vestibular assessment can help determine whether BPPV—or something else—is contributing to your symptoms.