Benign Paroxysmal Positional Vertigo (BPPV)

It’s not normal to be dizzy. I’m stating that right here from the outset because I’m always surprised by how many patients mention dizziness incidentally, as if they believe it’s something that they just have to live with. 

Numerous things can cause dizziness, including blood pressure issues, medication interactions or side effects, age-related balance problems, or even the neck. Thankfully, once the cause is identified, dizziness can be improved (or even resolved) in a lot of patients (Kundakci, 2018).

One of the most common causes of dizziness is a condition called BPPV (or benign paroxysmal positional vertigo). 


Yes, BPPV has a complicated name but its meaning becomes clear when you break down each word.

  • Benign: a mild condition that responds well to treatment
  • Paroxysmal: sudden symptom onset
  • Positional: relating to your body’s position
  • Vertigo: the false sensation that you or your surroundings are moving 

Benign paroxysmal positional vertigo symptoms

If you’ve developed BPPV, you may notice symptoms such as:

  • Dizziness
  • Feeling like the room is spinning around you (vertigo)
  • Losing your balance or feeling unsteady
  • Nausea
  • Vomiting.

Your symptoms may come and go in brief episodes. They’re usually brought on when you change your head position, for example by rolling over in bed or getting up from a chair. You may also experience unusual rhythmic eye movements alongside your symptoms.

How do you keep your balance normally?

You have a beautiful, complicated and finely calibrated mechanism for maintaining your balance, which usually allows you to stay upright and move confidently.

Your body is constantly fine-tuning your balance, integrating messages about your body’s position received from your inner ear, eyes, muscles, joints and brain.

A key part of this is the vestibular system in your inner ear. It comprises 3 semicircular canals and two otolith organs (like little pockets). When you move your head, small crystals stimulate tiny hairs, which transmit messages from your vestibular nerve (balance nerve) to your brain. It works beautifully – until it doesn’t.

What causes benign paroxysmal positional vertigo (BPPV)?

BPPV happens when those tiny calcium carbonate crystals (known as canaliths) detach from their usual position and fall into your ear canal. Even very small movements can cause those canaliths to move too, stimulating the nerves that tell your brain that your head is moving far more than it really is.

That upsets your brain's understanding of your head position, leading to dizziness (Palmeri & Kumar, 2020). Your poor brain is receiving mixed messages as your eyes, muscles and joints are saying one thing about your head’s position while your vestibular system says another.

So, what causes those crystals to fall incorrectly? BPPV can be caused by:

  • Head injury
  • Age-related degeneration of your vestibular system
  • An inner ear disorder that has damaged your vestibular system.

Associations have also been found between BPPV and:

  • Osteoporosis
  • Working as a dentist or barber because your head is often tilted.

Sometimes, though, there is no obvious cause of BPPV.

How can we tell if your dizziness is caused by BPPV?

Often in healthcare, we have to differentiate between different possible causes of a particular set of symptoms. Usually, assessment for dizziness is quite detailed, as we are trying to distinguish between the many causes of dizziness, and make sure that the cause of your symptoms isn’t something serious (which overall is quite rare).

With BPPV, we ask questions about:

  • Any particular tasks or positions that provoke symptoms
  • How long your dizziness lasts for
  • How you’d describe the dizziness (is the room spinning or do you just generally feel off balance?)
  • Whether you get any symptoms in between dizzy spells (Palmeri & Kumar, 2020).

Often, people with BPPV will describe short dizzy episodes (usually less than 1 minute) which are provoked by head movements, especially looking up, down or turning head to the side eg. rolling over in bed, with the sensation that the room around them is spinning or swaying, and often they have no particular symptoms between these attacks (You et al, 2020). That’s what we listen out for when we’re talking about your symptoms.

Once we’ve finished talking about your symptoms, we move onto a physical assessment. That involves:

  • Testing your visual system (as this works quite closely with your balance system),
  • Testing your balance and coordination
  • Determining which ear is causing vertigo using the Dix Hallpike test. Essentially, we lie you on an examination table then try to provoke your symptoms by positioning your head in certain ways.

Benign paroxysmal vertigo treatment

The good news is that there are well-researched treatments for BPPV with up to an 80% success rate (Gaur et al. 2015). For many people, dizzy symptoms can be reduced or even resolved completely. 

There are a number of techniques to treat BPPV including:

  • Giving it time – it may resolve by itself
  • Medication to relieve nausea or motion sickness
  • Canalith repositioning using the Epley manoeuvre. This technique involves moving your head in certain ways to shift the canaliths out of the canal so that they stop causing dizziness
  • Canal plugging surgery to stop the affected inner ear canal reacting to particle movements.

How can Sycamore Health help with BPPV?

Our physiotherapists at Sycamore Health can help your BPPV by:

  • Identifying it – as I said at the beginning, many people are just putting up with dizziness, not realising that it can be treated
  • Ruling out other possible causes
  • Treating your BPPV in the clinic using the Epley manoeuvre
  • Showing you home-based exercises to relieve your symptoms.

Bottom line? You’re not supposed to feel dizzy. If you are having episodes of dizziness, it’s time to find out what’s going on. Book an appointment today.

All information is general in nature. Patients should consider their own personal circumstances and seek a second opinion.

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