What is BPPV, and how do repositioning manoeuvres work?

What causes BPPV?

The inner ear contains small calcium carbonate crystals attached to a sensory membrane that detects gravity and linear movement. These crystals can come loose and drift into one of the fluid-filled semicircular canals, which normally detect head rotation. When the head moves into certain positions, the crystals move within the canal and send a false signal that the head is spinning.

BPPV is more common with age. It can also follow a head injury, a period of bed rest or an inner ear infection, but often no trigger is found. The posterior canal is affected most often.

What are the symptoms?

The typical symptom is a sudden, intense spinning sensation that lasts less than a minute, triggered by changes in head position: lying down, turning over in bed, sitting up, looking up to a shelf or bending forwards 1. Nausea is common. Between episodes, people may feel slightly off balance or unsteady.

Because symptoms are brief and positional, people often learn to avoid movements that trigger them. In older adults, sudden dizziness when getting out of bed can lead to falls.

How is BPPV diagnosed?

BPPV is diagnosed clinically. For the most common type, the clinician performs the Dix-Hallpike test, moving the person quickly from sitting to lying with the head turned and tilted slightly back while watching for characteristic eye movements. The combination of positional vertigo and these eye movements confirms the diagnosis.

Clinical guidance recommends that brain imaging, vestibular testing and anti-dizziness medicines are not routinely needed for typical BPPV 1. They are used when features suggest another cause.

How do repositioning manoeuvres work?

Repositioning manoeuvres use a series of head and body positions so that gravity moves the crystals out of the semicircular canal and back into the part of the inner ear where they do not cause symptoms. For posterior canal BPPV, the Epley manoeuvre is the most widely used. Different manoeuvres are used for the less common canal types.

Guidance recommends treating posterior canal BPPV with a repositioning procedure 1. Many people improve after one or two treatments 1. Brief dizziness during the manoeuvre is expected and usually shows the correct position is being reached.

What happens after treatment?

Some people feel slightly unsteady or foggy for a few days after successful treatment. Strict restrictions on head movement after the manoeuvre are generally not required. If symptoms persist, the test is repeated and treatment repeated or adjusted for a different canal.

Vestibular rehabilitation, a programme of balance and gaze exercises, can help people who have lingering unsteadiness, and it is an option in the management of BPPV 12. It also helps people who have reduced their activity because of fear of dizziness.

Can BPPV come back?

BPPV recurs in a substantial proportion of people, sometimes months or years later. Recognising the symptoms early allows prompt treatment. Some people are taught a version of the manoeuvre to do at home, although it should be learned from a clinician first to make sure the correct side and canal are treated.

People with repeated episodes and falls benefit from a balance and fall risk review, including vision, medicines, blood pressure and home safety.

When is dizziness not BPPV?

Dizziness that is constant, lasts hours or days, comes with new double vision, slurred speech, facial droop, weakness, numbness, severe headache, or difficulty walking even when not moving the head needs urgent assessment, as it may indicate a stroke or other brain condition.

Dizziness with hearing loss, ringing in the ear or a feeling of fullness points to other inner ear conditions. Dizziness on standing may be due to low blood pressure. These require different assessment and treatment.

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