Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, caused by loose calcium crystals (otoconia) moving into a semicircular canal of the inner ear. Certain head movements then trigger brief spinning that settles within a minute.
Key symptoms
- Brief spinning lasting under a minute
- Triggered by rolling over in bed, looking up or bending down
- Nausea during episodes
- Mild imbalance between episodes, no hearing loss
What you find on exam
- Dix-Hallpike: delayed, brief upbeating twisting nystagmus toward the lower ear (posterior canal)
- Supine roll test for horizontal canal BPPV
- Normal neurological exam, including gait and cranial nerves
- Normal hearing on tuning fork tests
Tests
- Diagnosis is clinical, from history and positional tests
- No routine imaging or vestibular testing
- MRI if the nystagmus is atypical, there are neurological signs or treatment fails
Treatment basics
- Epley maneuver for posterior canal BPPV
- Barbecue roll or Gufoni maneuver for horizontal canal BPPV
- Avoid long use of vestibular suppressants such as meclizine
- Teach home exercises and fall prevention; recurrence is common
Red flags
- Vertigo with headache, double vision, slurred speech or weakness
- Nystagmus that changes direction with gaze or does not fade
- Cannot stand or walk without help
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.