BPPV — The Most Common Type of Vertigo

What is BPPV?

Benign Paroxysmal Positional Vertigo (BPPV) is the most common type of peripheral vertigo, accounting for approximately 20-30% of all vertigo cases. It is caused by the displacement of small calcium carbonate crystals (otoliths) from the utricle into the semicircular canals of the inner ear.

The good news: although the symptoms are frightening, BPPV is benign, with simple and effective treatment in over 90% of cases.

Why it occurs

The inner ear contains a vestibular system with 3 semicircular canals and 2 otolith organs. The utricle contains small calcium carbonate crystals — otoconia — that help detect gravity.

When these crystals detach and migrate into a semicircular canal (most commonly the posterior canal), they create abnormal endolymph movements when the head position changes. The brain receives contradictory signals → result: rotatory vertigo.

Common causes:

• Degenerative / aging — the most common cause (more frequent after age 50)
• Head trauma — even mild
• Post-vestibular neuritis
• Prolonged bed rest
• Idiopathic — the cause often remains unknown

Characteristic symptoms

• Intense rotatory vertigo — typical duration: 15-60 seconds
• Triggered by position — turning in bed, getting out of bed, tilting the head
• Nystagmus — involuntary eye movements
• Nausea and vomiting — in severe episodes
• Postural instability between episodes
• No hearing loss, no tinnitus — hearing is normal

When should you see a doctor?

Warning signs (possible central, neurological vertigo):

• Continuous vertigo lasting hours to days without pause
• Severe associated headache
• Vision, speech or coordination disturbances
• Numbness or weakness on one side of the body
• Sudden hearing loss

Diagnosis

The diagnosis is clinical, through diagnostic maneuvers:

• Dix-Hallpike maneuver — the standard test for posterior canal BPPV. Rotatory nystagmus appears with a latency of 2-5 seconds, lasting less than 1 minute.
• Roll test (Pagnini-McClure) — for lateral canal BPPV.

Treatment — repositioning maneuvers

Epley maneuver

The first-line treatment, with 80-95% efficacy after 1-3 sessions. It consists of 5 head positions that guide the otoliths back into the utricle. It takes 5-10 minutes.

Lempert maneuver (BBQ roll)

For lateral canal BPPV — 360° body rotations in 90° steps.

After the maneuver

Sleeping with the head elevated 30° for the first 1-2 nights, avoiding sudden movements for 24-48 hours.

Medication

Anti-vertigo medication (betahistine) has only a symptomatic role — it does not treat the cause.

Prognosis

Excellent. Most patients are asymptomatic after 1-3 sessions. Recurrence rate: ~15-20% per year. Brandt-Daroff exercises performed at home can reduce the risk of recurrence.