BPPV – SYMPTOMS, DIAGNOSIS & TREATMENT 2017-10-13T09:50:53+00:00

BPPV – Symptoms, Diagnosis & Treatment


One of the most prevalent causes of vertigo is Benign paroxysmal positional vertigo (BPPV). It presents with the symptom of sudden sensation that you’re spinning on change of position or while turning in bed. BPPV is an inner ear problem. It ensues when some of the calcium carbonate crystals (otoconia) that are typically embedded in the gel in the utricle become displaced and migrate into one or more of the three fluid-filled semicircular canals, where they should not be. When these otoliths accumulate in one of the canals in the inner ear, they meddle with the natural fluid movement that these canals use to sense head motion, causing the inner ear to send false signals to the brain.

The spinning sensation or vertigo lasts less than one minute. Between vertigo spells, some people feel no symptoms, while others feel a mild sense of imbalance or disequilibrium.


There are many causes of BPPV. Some of the prevalent ones are:

  • Head injury
  • Ear infection
  • Ear inflammation
  • Ear surgery
  • Old age


If you are suffering from BPPV, you will often sense that you have lesser or no control over your body. You may seem to be leaning or turning involuntarily, especially when sleeping, bending over, looking up with your head tilted back or turn around your head suddenly.

The symptoms of benign paroxysmal positional vertigo (BPPV) may include:

  • Dizziness
  • A feeling that your surroundings are spinning or moving (vertigo)
  • A loss of balance or unsteadiness
  • Nausea
  • Vomiting

The symptoms of BPPV can waver, with indications commonly lasting less than one minute. Episodes of benign paroxysmal positional vertigo can disappear for some time and then recur.

Movements that bring about the symptoms of BPPV can differ from person to person. But we have observed that more often than not the symptoms are triggered when the BPPV prone person changes his head position. Some people also feel off-balance when they are standing or walking.

Abnormal rhythmic eye movements, called as nystagmus usually accompany the symptoms of benign paroxysmal positional vertigo.


When someone with BPPV moves their head into a particular position that makes the dislodged crystals move within a canal, the wrong signals cause the eyes to move in a very distinct pattern, referred as “nystagmus”.

The connection between the inner ears and the eye muscles allow us to stay focused on our environment while the head is moving. Since the dislodged crystals usher the brain to think that the person is moving when in reality he is not, it falsely causes the eyes to move, which makes it look like the room is rotating. The eye movement provides the hint that something is happening in the inner ear canals that are moving the fluid when it shouldn’t have moved.

The nystagmus will have different characteristics that allow a trained practitioner to recognise which ear is disturbed by the displaced crystals, and in which canal or canals they have moved.

Tests like the Dix-Hallpike or Roll Tests involve moving the head into specific positions, which makes gravity to migrate the dislodged crystals and trigger vertigo while the practitioner watches for the revealing eye movements or nystagmus. These tests when done under VNG guided magnification and recording allow an exact diagnosis of the position of the otolith particles.


The specialist doctors conduct a Dix-Hallpike test to diagnose BPPV along with few questions to check the severity of your vertigo. The Dix-Hallpikeexamination tests the eyes of the BPPV patients while she lies back or turns her head. Any involuntary eye movements indicate the cause of dizziness. The problem may be in the inner ear, brain or nerve endings. The nerve endings are connected to the inner ear and transmit signals to the brain to help balance the body. The doctors can trace the origin of BPPV with the aid of this test.

The Dix-Hallpike test also helps the doctor to diagnose which ear has the problem and treat accordingly.



There are two kinds of BPPV: Canalithiasis and Cupulolithiasis.

In Canalithiasis, the loose crystals can move freely in the fluid of the canal.

The other hand, Cupulolithiasis, is a rare pattern of otolith dislodgement. In this condition, the crystals get stuck on the bundle of nerves that sense the fluid movement.

In canalithiasis, it takes less than a minute for the crystals to stop moving after the head position is changed to a particular angle that has triggered vertigo. The fluid movement settles, once the calcium carbonate crystals stop moving. Subsequently, nystagmus and vertigo stop too.

In cupulolithiasis, the crystals attached to the bundle of sensory nerves cause the nystagmus, and vertigo lasts pretty longer until the head is moved out of the offending position. It is important to make this distinction, as the treatment is different for each variant.

MRI does not help in the diagnosis of BPPV.



BPPV medication does not provide a lasting solution. They are meant to suppress the BPPV indications and ease the uncomfortable sensations in the patients.  One should not take vestibular suppressants for a longer duration due to their adverse side-effects and addictive nature.

If the cause of BPPV is ear infection or inflammation, the doctors prescribe antibiotics and other medications. For BPPV resultant vertigo or spinning sensation, doctors prescribe vestibular suppressants like antihistamines, scopolamine, and sedatives. The medical practitioners also suggest antiemetics to treat acute nausea and vomiting associated with severe vertigo cases.

Medicines do not help in the treatment of BPPV. Surgical treatment is required only in sporadic cases where benefits of BPPV exercises are limited.


BPPV can be corrected mechanically by different repositioning maneuvers depending on the position of the particles. Once your health care provider diagnoses which canal or canals the crystals are in and what type of BPPV it is (canalithiasis or cupulolithiasis), then he can take you over the suitable maneuver.

The maneuvers use gravity to guide the crystals back into their chamber where they belong via a particular sequence of head positioning called Canalith Repositioning Maneuvers.

In the case of cupulolithiasis, they would utilise quick head movement in the level of the affected canal to try and dislodge the ‘hung-up’ crystals first, called a Liberatory Maneuver.

Epley’s maneuver is one of the most commonly used maneuver to treat BPPV. However, that will not work for all types of BPPV.

Often people try the Epley’s maneuver themselves or have it performed on them by a practitioner, without seeing any success. Later assessments reveal that it is a different maneuver that should have been used, instead of Epley Maneuver. Or sometimes, the condition may have been wrongly diagnosed as BPPV, where in reality it is not BPPV at all!

Other maneuvers used for canalith repositioning include the Semont’smaneuver, Gufonimaneuver, Vanucchimaneuver, deep head hanging, reverse Epley, etc. These exercises are recommended for different kinds of BPPV. That is why doctors urge caution while using self-treatment or being treated by someone who is not trained in identifying different variants of BPPV and several treatment exercises.

Over a period the brain gets habituated and ignores the erratic signals it is receiving. Brandt – Daroff exercise is beneficial in compensating the brain to ignore the false signals triggered by the otoliths.


Epley and Semont exercises help immensely in repositioning the canaliths in the ear to reduce vertigo. The canalith repositioning activities show drastic results in just a couple of sessions; especially when the patient does it under expert supervision.


This exercise is popularly preferred to treat BPPV. When an experienced doctor conducts Epley maneuver on a BPPV patient, it can bring about almost instantaneous results.

A session of 10-15 minutes is sufficient to treat a mild BPPV. But it is advised to be done under a specialist doctor’s supervision. At NeuroEquilibrium, the trained professionals assist the BPPV patients with Epley maneuver and monitor the results.

How ToDo Epley Maneuver?

Step 1: First, you sit on the table with your legs stretched straight in front of you.

Step 2: The therapist will turn your head to the right at 45 degrees.

Step 3: This step may cause vertigo. The therapist will swiftly help you lie on your back while still holding your head at 45 degrees angle, to your right.  Slightly suspend your head at the edge and let your shoulders rest on the table.

Step 4: This position should be held for about 30 seconds or until your vertigo ceases.

Step 5: Now, turn your head to the opposite side, so that it is 45 degrees to your left.

Step 6: Hold this position for 30 more seconds or until your vertigo ceases.

Step 7: Turn to your left side and be there for 30 seconds more. Note that, you should not turn to the side which has vertigo problem.

Step 8: Get up slowly, sit on the edge of the table until you feel comfortable to stand up.

The doctor will help to manoeuvre your head swiftly from one side to another so that the canaliths move back to their place and settle down.


This head-turning exercise is best assisted by a trained doctor or a therapist. Similar to the Epley maneuver, semontmaneuver too helps the canaliths reposition to their original place and stop causing vertigo in the patient.

How ToDo SemontManeuver?

Step 1: Your doctor will suggest you sit on the table with your legs down.

Step 2: If you have a problem on the left side, the therapist will turn your head to the right at 45 degrees. Vice-versa if you have a problem on your right side.

Step 3: Holding your head at 45 degrees to your right you will be made to sleep on your left side, with your nose facing up.

Step 4: Be in this position for 30 seconds.

Step 5: Now, holding your head in the same state, you will be held up, and swiftly moved to the opposite side. In this position, your nose will be pointing down at the table.

Step 6: Hold this position for 30 more seconds.

Step 7: You will be helped to sit back gently on the table until you feel fit to stand up.

Epley and Semontmaneuvers are very efficient to treat BPPV in few sittings. That makes them popular and the first choice of treatment for BPPV.



This exercise helps the brain cope with the confusing signals it receives, as a result of inner ear issues. Brandt-Daroff exercise is done two-three times daily, for several weeks to get the desired results.

How ToDo Brandt-DaroffExercise?

Step 1: Sit straight on the bed with your legs down.

Step 2: Sleep on your right side with your head turned  45 degrees to your left.

Step 3: This position is to be held for 30 seconds or until your vertigo symptoms subside.

Step 4: Sit back as in step 1.

Step 5: Sleep on your left side with your head turned 45 degrees to your right.

Step 6: Hold this position for 30 more seconds.

Step 7: Get up and sit on the bed for a while until you feel ready to stand up.


Your doctor may suggest these balancing exercises to do at home that reduce the symptoms of BPPV.

How ToDo Balancing Exercises?

  • Stand straight with your feet placed together
  • Keep your arms straight down
  • Move your head sideways, very slowly


The doctors recommend ear surgery as a last alternative when none of the above treatment works. The surgery is an invasive treatment modality and may give rise to certain complications, for instance, loss of hearing ability or injury to facial nerves.

Some of the types of surgeries that can be performed to treat BPPV are singular neurectomy, trans-tympanic aminoglycoside, labyrinthectomy, vestibular nerve section, and posterior canal occlusion.


Along with medications and head turning exercises, follow these simple yet powerful tips to keep a check on BPPV symptoms.

  • Don’t bend over.
  • Every time you get up from the bed, follow this simple procedure; roll over to your side, get up slowly without causing any jerking movements and sit for a while on the bed before standing up.
  • Don’t sleep on the side that has an ear problem and is the cause of BPPV.
  • Keep your head elevated with the help of pillows while sleeping.
  • Avoid moving your head in the direction that is causing vertigo; such as bending over, turning your head sideways, up and down, or lying on your back.
  • Avoid activities such as gymnastics, and some sports that require flips and sudden movements.


In general scenario, BPPV does not affect patients severely. If it does, you should seek medical attention immediately.

Emergency Conditions Requiring Immediate Medical Help:

  • Difficulty in breathing
  • Difficulty in seeing
  • Falling off
  • Stroke
  • Fainting
  • Balance disorder
  • Mild paralysis in any part of the body
  • Feeling numb or weak in any part of the body
  • Feeling disoriented
  • Unbearable headache
  • Incessant vomiting
  • Loss of hearing ability
  • Chest pain

CONCLUSION: BPPV treatment modalities include medication, exercises or surgery. BPPV medications cause adverse effects if used for a prolonged period and are only suppressants of the symptoms. Surgery for BPPV provides around 80-90% relief but is complicated and risky. The exercises recommended for BPPV are proven to be extremely effective when done under specialist’s supervision.

NeuroEquilibrium has sophisticated devices to diagnose BPPV and offer customised medical treatments for patients suffering from vertigo and balance disorder issues.

Collaborate with us to set up advanced vertigo and balance clinics or buying NeuroEquilibrium™ equipment. Please drop us an email at partner@neuroequilibrium.in






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