Benign paroxysmal positional vertigo (BPPV)

Vertigo is described as feeling like you are turning around when you are actually standing still. ‘Benign paroxysmal positional vertigo (BPPV) is characterised by brief recurrent episodes of vertigo triggered by changes in head position.’


Inside the inner ear is a series of canals at different angles, filled with fluid. When the head is moved, the fluid inside these canals tells the brain exactly how far, how fast and in what direction the head is moving. BPPV is thought to be caused by calcium carbonate crystals (otoconia) held in special reservoirs within the canals. It is thought that injury or degeneration allows the otoconia to escape into the canals and interfere with the fluid flow. Patients with BPPV usually do not experience vertigo during usual daytime activities performed with an upright posture. Common triggers of BPPV include rolling over in bed, getting out of bed, lifting the head to look up, for example to look up at shelves, or bending forward, for example when fastening shoes. Symptoms of BPPV vary among patients, and may manifest with nonspecific dizziness, postural instability, light-headedness, and nausea. The duration, frequency, and symptom intensity of BPPV vary depending on the involved canals and the location of otoconia.


A high prevalence of BPPV in middle-aged women, indicates hormonal factors may play a role in the development of BPPV. It has also been found that ‘bone mineral density score was decreased in both women and men with BPPV. The prevalence rates of osteopenia (low bone density) and osteoporosis (disease characterised decrease in bone mass and density) were also found to be higher in both women and men with BPPV. BPPV may develop secondary to various disorders that damage the inner ear and detach the otoconia. Head trauma causing mechanical damage to the ear is a common cause. In addition, BPPV may develop secondary to any of the inner ear diseases (e.g., vestibular neuritis, labyrinthitis, and Meniere’s disease) that give rise to degeneration and detachment of the otoconia.


BPPV is usually a self-remitting disorder and may resolve with time, without specific treatment. Recovery can be expected with conservative treatments. Positioning manoeuvres usually provide an immediate resolution of symptoms by clearing the otoconia from the canal. Routine medications such as vestibular suppressants are not recommended however, clinicians may prescribe medications to reduce the spinning sensations or reduce the accompanying motion sickness symptoms. Vestibular suppressants are not as effective as positioning manoeuvres for BPPV.


Surgical treatments may be considered in the rare occasion when persistent vertigo or frequent recurrences are refractory to repositioning manoeuvres. Transection of the posterior ampullary nerve innervating the posterior canal (singular neurectomy) or posterior semicircular canal occlusion (canal plugging) have been performed for intractable BPPV. However, surgical intervention should be waived until all conservative treatments have been attempted and failed.


Vertigo often recurs in BPPV, with reported recurrence rates of 15-37% after effective initial positioning manoeuvres. Most recurrences (80%) occur within the first year after treatment. ‘Factors associated with a higher recurrence rate include being female, presence of preceding illnesses such as trauma, inner ear disease, presence of osteopenia/osteoporosis, Horizontal Canal-BPPV, and a history of three or more BPPV attacks prior to treatment.’


Workplace Physiotherapy has staff trained in the development of management strategies for BPPV.


Ref: Seung-Han Lee, MD and Ji Soo Kim, MD, PhD. Benign Paroxysmal Positional Vertigo J Clin Neurol. Jun 2010; 6(2): 51–63.


The comments above are the implicit advice of Workplace Physiotherapy. The views expressed are based on current evidence-based research and accepted best practice approaches. Unless otherwise stated, these comments are not the view of WorkCover NSW or any other professional body. No reproduction or forwarding of this advice is permitted without the consent of the author.


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