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REVIEW
Evaluation and Treatment of Benign
Paroxysmal Positional Vertigo
Janet Odry Helminski, PhD, and Timothy Carl Hain, MD
Benign paroxysmal positional vertigo
(BPPV) is characterized by brief
periods of vertigo triggered by a
change in the position of the
patient’s head relative to gravity. The
diagnosis of BPPV is based on the
patient’s history and eye movements
(nystagmus) evoked during two
positional tests: the Dix-Hallpike
maneuver and the supine with
lateral head turns maneuver. The
direction and characteristics of the
nystagmus found during the positional
testing enable the clinician to determine the canal involved. Once the
involved canal is identified, BPPV
may be effectively treated with a
physical maneuver. The maneuvers
may be performed by a clinician or
by patients themselves. (Annals of
Long-Term Care: Clinical Care and
Aging 2007;15[6]:33-39)
Dr. Helminski is in the Department of
Physical Therapy, Midwestern University, Downers Grove, IL; Dr. Hain is in
the Departments of Physical Therapy
and Human Movement Performance,
Otolaryngology, and Neurology,
Northwestern University Medical
School, Chicago, IL.
33
INTRODUCTION
Benign paroxysmal positional vertigo (BPPV) is the single most common cause of vertigo. BPPV accounts for 26% of all cases of vertigo1
and was found in 9% of geriatric patients in an urban clinic.2 The incidence of BPPV increases with age.1,3 BPPV affects the quality of life of
elderly patients and is associated with reduced activities of daily living
scores, falls, and depression.2 The purpose of this article is to review the
evaluation and treatment of BPPV.
CLINICAL FEATURES OF BPPV
BPPV is characterized by brief periods of vertigo triggered by a change in
the position of the patient’s head relative to gravity. Brief periods of vertigo typically occur when the patient rolls in bed towards one side, gets in
and out of bed (“bed-spins”), bends over and straightens up, or looks up
(top-shelf syndrome).4,5 If one observes the patient’s eyes during these periods, one can sometimes observe that the eyes are jumping. The rapid,
involuntary oscillation of the eyes is referred to as nystagmus. Patients with
BPPV are usually most symptomatic while lying flat in bed and often
adopt sleeping strategies such as propping themselves up in bed.
There are three main variants of BPPV. Each variant is characterized
by a specific direction of nystagmus, and the direction is dependent on
the part of the inner ear that is causing the vertigo. In the most common variant, posterior canal BPPV (PC-BPPV; see Figure 1 for the location of the posterior canal), the eyes jump upward as well as twist. In
the second most common variant, horizontal canal BPPV (HC-BPPV),
the eyes jump horizontally. The least common type is anterior canal
BPPV (AC-BPPV), where the eyes jump downward.
Most BPPV is caused by loose particles within the inner ear. This is
more formally called canalithiasis (Figure 1).6 In canalithiasis, heavy
debris from another part of the ear (the utricle) becomes dislodged and
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mus, and this is the main feature that distinguishes
BPPV from other types of positional vertigo. More
about the nystagmus follows in the next section.
POSITIONAL TESTING TO DIAGNOSE BPPV
Figure 1. Mechanisms of BPPV.
© 2007, American Dizziness and Balance. Reprinted with
permission.
enters a semicircular canal. The debris, being made
of calcium carbonate (limestone), is heavier than the
fluid in the canal. Thus, when the position of the
head changes relative to gravity, the debris falls
downward in the semicircular canal. As the debris
falls, the patient experiences a brief burst of vertigo
and nystagmus. Once the debris comes to rest, typically in 10-60 seconds, the nystagmus and vertigo
stops. PC-BPPV is the most common because the
PC is at the bottom of the inner ear, and this promotes accumulation of heavy debris.
DIFFERENTIAL DIAGNOSIS OF BPPV
BPPV causes about 85% of all positional vertigo.
Orthostatic hypotension and other conditions that
cause low blood pressure also result in positional symptoms, but symptoms are triggered by standing up, and
typically no symptoms are noted when the person is
supine. Damage to the brainstem or cerebellum can
also cause positional vertigo. Central positional vertigo
is far less common than BPPV, is accompanied by
other neurological signs, and also generally shows a different pattern of nystagmus on positional testing, as
discussed subsequently. Low spinal fluid pressure can
also cause orthostatic symptoms, but again like orthostatic hypotension, they are not prominent when lying
in bed. All types of BPPV are accompanied by nystag-
34
The diagnosis of BPPV is established through two
positional tests; the Dix-Hallpike maneuver7 and the
supine with lateral head turns maneuver.8 Determining the canal involved is based on the direction and
characteristics of the nystagmus found during the
positional testing. Positional testing is best performed
with an examination tool that prevents fixation, such
as the patient wearing Frenzel goggles or using videooculography. When positional testing is done without a method of removing fixation, only very strong
nystagmus may be easily appreciated.
The Dix-Hallpike maneuver (Figure 2A) is used to
diagnose both PC- and AC-BPPV. It tests for BPPV in
the ipsilateral PC and contralateral AC. In both cases,
debris within the canals moves to a new lowest position,
in response to a repositioning of the head (Figure 2B).
Figure 2A. DixHallpike Maneuver
illustrated for the
head-right position
without Frenzel goggles. The patient is
positioned in long
sitting (sitting on the
treatment table with
the legs extended).
The patient’s head is
rotated 45 degrees
towards the right.
The patient is then
lowered into supine
with the neck extended 20 degrees over the edge of the
treatment table. The position is maintained for 45 seconds.
The procedure is then repeated towards the left. For each
position, the clinician notes the direction and characteristics of the nystagmus. 2B. In the head-right position, if
BPPV involves the right PC, a torsional towards the lowermost ear and upbeating nystagmus is observed.
© 2007, American Dizziness and Balance. Reprinted with
permission.
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For PC-BPPV, the top of the eye jumps upward and
twists rapidly towards the lowermost ear (Figure 2B).
For AC-BPPV, the maneuver generates a mainly downbeating nystagmus. In both PC-BPPV and AC-BPPV,
the nystagmus occurs as a burst (lasting < 60 sec),
because after the debris has moved to the new lowest
part of the canal there is no further stimulation. For
both types, there is a brief burst of nystagmus with
reversed direction when the patient sits up and the
debris moves back towards the cupula.
The other positional test, supine with lateral head
turns (Figure 3) is used to detect HC-BPPV.8 In this
test, the patient begins by lying supine, but the head
is tilted forward 30 degrees, aligning the plane of the
HC with gravity. This can be conveniently done
using a pillow. Then the head is rotated 90 degrees
towards the right, to center, and 90 degrees towards
the left, pausing about 30 seconds in each position.
A positive test and diagnosis of HC-BPPV occurs
when there is a strong horizontal nystagmus that
changes direction between the head-right and headleft positions.
In addition to direction, the timing of nystagmus
also varies with the canal involved (Table I). The vertigo of HC-BPPV tends to be more intense than PCor AC- BPPV and is more likely to be associated with
nausea and vomiting.9,10
In the clinic, BPPV is predominantly PC in type.
However, when one records the eyes using more
sensitive methods such as video-oculography, there
is a broader mixture of types of BPPV, with about
41-65% being unilateral PC-BPPV, about 20% multiple-canal BPPV, 21-33% HC-BPPV, and 17%
AC-BPPV.11,12 The difference between clinical
observation and laboratory data may be caused by a
Figure 3. Supine with lateral head turns positional test
illustrated without Frenzel goggles. The patient is positioned sitting, and the head is rotated 90 degrees towards
the right. The patient is lowered into supine with the neck
flexed 20-30 degrees forward. The head is then rotated 90
degrees towards the left to midline, and then 90 degrees
towards the left. Each position is maintained for 30 seconds. For each position, the clinician notes the direction
and characteristics of the nystagmus.
© 2007, American Dizziness and Balance. Reprinted with
permission.
difference in technique. In the clinic, especially when
optical Frenzel goggles are used, fixation may be
impaired but still possible. Thus, only nystagmus
that cannot be suppressed with fixation, such as the
torsion of PC-BPPV, may be observed.
With respect to the natural history, in patients
diagnosed with BPPV within 3 days of onset of
symptoms, 30% of the patients with PC-BPPV and
53% of the patients with HC-BPPV went into remission within 7 days.12 This is probably because debris
tends to spontaneously move out of the HC into the
vestibule, but tends to stay in the lower part of the
inner ear, the PC.
Table I: Varying Characteristics of Nystagmus with Canal Involved
Canal Involved
Latency before Onset (s)
Duration of Nystagmus (s)
Fatigues with Repeated Positioning
Posterior (PC)
1-20
<60
Yes
Horizontal (HC)
<341
>6041
No8
Anterior (AC)
0-542
<6042
Yes42
35
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TREATMENT OF BPPV
Once the involved canal is identified, BPPV may be
effectively treated with a particle repositioning
maneuver designed to treat the canal involved.
Treatment of PC-BPPV
Several particle repositioning maneuvers have been
developed to treat the PC. Historically, the first maneuver was the Brandt-Daroff exercise,13 designed to selftreat BPPV with repeated symptom-provoking movements. The patient moves from sitting on the edge of
the bed to lying on the side, placing the plane of the PC
of the lowermost ear vertical with gravity. The patient
alternates between movements towards the left and
right sides. Therefore, identification of the side
involved was not necessary. This exercise has fallen out
of favor, as newer maneuvers are more effective.
The canalith repositioning procedure, or Epley
maneuver,14 is presently the most commonly used
treatment for BPPV. It uses gravity to move particles
out of the sensitive part of the ear (ampullary region)
into an insensitive part of the ear, the vestibule (Figure
1). The clinician moves the patient through a series of
Figure 4. Canalith
repositioning procedure illustrated
for treatment of
the right PC. The
clinician moves
the patient
through a series of
4 provoking positions, starting with
the placement of
the involved canal
in the head-hanging position of the Dix-Hallpike maneuver,
then rotating the head 90 degrees towards the uninvolved
side, followed by rolling onto the uninvolved side maintaining the head on trunk position, and finally sitting up from
lying on the side. Each position is maintained for a minimum of 30 seconds or as long as the nystagmus lasts. The
procedure is repeated 3 times.
© 2007, American Dizziness and Balance. Reprinted with
permission.
36
Figure 5. Self-canalith repositioning procedure illustrated
for treatment of the right PC. The head is extended over the
edge of the pillow instead of the edge of the bed. Each
position is maintained for a minimum of 30 seconds or as
long as the nystagmus lasts. The patient performs 3 cycles,
3 times per day. Exercises are stopped when the patient is
symptom-free for 2 consecutive days.
© 2007, American Dizziness and Balance. Reprinted with
permission.
positions (Figure 4). With each position, the otoconia
fall to the lowest part of the canal. This results in the
movement of the debris around the arc of the long arm
of the PC, through the common crus, and into the
insensitive vestibule. Each position is maintained for a
minimum of 30 seconds. While Epley applied vibration to the mastoid process of the involved side during
the maneuver, this does not appear to be necessary.15-17
Another maneuver, the Liberatory or Semont maneuver, is also in common use.18 The geometry and results
of the Semont maneuver are very similar to the canalith
repositioning procedure.
The canalith repositioning procedure has been
modified to enable patients to treat themselves at
home. With the self-canalith repositioning
procedure,19,20 (Figure 5), the patient moves through
the same four positions as the canalith repositioning
procedure, except that the head is extended over the
edge of a pillow instead of the end of a treatment table.
Treatment of HC-BPPV
Multiple treatment techniques have been advocated
for HC-BPPV.21-25 Again, there is an attempt to use
gravity to move the debris out of the canal into the
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BPPV —
An example of this is the forced positional procedure of
Crevits.26 In this maneuver, the patient is positioned
supine with the head extended over the edge of the
treatment table as far as possible, and the head is then
brought back forward.
Activity Restrictions Post-Maneuvers
Figure 6. Log Roll illustrated for treatment of
canalithiasis of the right HC. To begin, the patient is
positioned in supine with the head rotated 90 degrees
towards the involved ear. The head and body are rotated
at 90-degree increments towards the unaffected ear for a
total of 360 degrees. Each position is maintained for 30
seconds. The patient performs 3 cycles, 3 times per day.
Exercises are stopped when the patient is symptom-free
for 2 consecutive days.
© 2007, American Dizziness and Balance. Reprinted with
permission.
vestibule by rotating the patient around the body’s
vertical axis in the recumbent position. We will call
these variants the log roll maneuvers. The maneuvers
vary with the degree of rotation about the vertical
axis, the initial position of the head in the supine
position, and the amount of cervical flexion in the
supine position. A common variant (Figure 6)
described by Epley23 is a 360-degree turn towards the
unaffected side, beginning supine, with the head
rotated 90 degrees towards the affected side. This
maneuver may also be used at home.
Treatment of AC-BPPV
Ordinarily, clinicians will first attempt to treat ACBPPV with the canalith repositioning maneuver done
on the side that elicits nystagmus, and if this fails, they
proceed to a more specific maneuver. Maneuvers
designed specifically to treat AC-BPPV are based on
taking the head into a “deep” position, beyond supine,
so as to allow debris to fall away from the cupula (Figure 7). Because of the more sagittal orientation of the
AC, maneuvers may start with the head straight back.
37
Post-maneuver activity restrictions are often advocated.
They are intended to prevent the debris from moving
back into the semicircular canals. Patients without
activity restrictions require more treatment sessions
before being cured than patients with activity restrictions.27 Restrictions include sleeping upright or at a 45degree angle, avoiding lying on the involved side,
refraining from vertical and rapid head movements,
and wearing a cervical collar to prevent head movements.28 Restrictions are maintained from 24 hours up
to 1 week.
Complications. Complications are reported with
maneuvers performed by the clinician29-32 and selftreatment.33,34 Complications include those related
to movement of debris into another location, nausea, vomiting, imbalance, and anxiety related to
treatment.29-34
Canal conversion is the result of debris from the
canal being treated, refluxing into another semicircular
canal. Horizontal canal conversion is common. It is
most frequently seen after treatments for PC-BPPV or
AC-BPPV. It is easily diagnosed by observing replacement of the vertical/torsional nystagmus of BPPV
Figure 7. Deep DixHallpike for treatment
of AC-BPPV. The
patient is moved from
sitting to supine, with
the head extended over
the edge of the treatment table. The head is
moved forward, and
then the patient sits up. Both positions are held for 2 minutes. The procedure is repeated 3 times.
© 2007, American Dizziness and Balance. Reprinted with
permission.
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involving the vertical canals with a powerful horizontal,
direction-changing nystagmus. Canal conversion is
particularly common in persons who self-treat with the
Brandt-Daroff exercises. During the office maneuvers,
eye movements are monitored, allowing easy identification of canal conversion. Once identified, the appropriate canal is treated.
A far rarer complication is canal jamming. In this
case, debris moves from a wider to a narrower segment
and plugs the canal.35 The patient experiences extreme
vertigo and develops a persistent nystagmus irrespective of the head position. To treat a canal jam, reverse
the direction of the maneuver that created the jam.
Apply gentle vibration to the mastoid process of the
involved side.
Nausea and vomiting are an intrinsic risk of provoking vertigo in diagnostic or treatment maneuvers. Patients known to be susceptible to vomiting
may be given antiemetics such as ondansetron,
promethazine, or meclizine 30 minutes prior to the
treatments.36
The majority of patients respond very well to treatment. However, following treatment, some patients
may complain of an increase in symptoms of generalized dizziness lasting a few hours to several days. This
situation is more likely when patients are treating themselves with home exercises. Typically, with self-treatments, patients perform many more cycles of the
maneuvers per week than in the clinic. Some may not
tolerate this due to nausea and vomiting, and medication may be necessary to reduce these symptoms. When
self-treating, a canal conversion may occur, necessitating
a visit to the clinic to diagnose and change the exercise
appropriately. Patients should stop exercises and contact
their clinician if symptoms that are initially unilateral
become bilateral, or if symptoms switch sides.
Recurrence of BPPV. BPPV often recurs. For PCBPPV, 25% of cured patients redevelop BPPV within 1 year, and 44% redevelop BPPV within 2
years.15,37 A daily routine of Brandt-Daroff exercises
does not affect the time to recurrence or the rate of
recurrence of PC-BPPV.38
38
EVIDENCE SUPPORTS PARTICLE
REPOSITIONING MANEUVERS IN
BPPV TREATMENT
Overall, PC-BPPV is treated effectively with particle
repositioning maneuvers such as the canalith repositioning procedure.14 The short-term success rate of
the canalith repositioning procedure ranges from
67-95%,3,28,31,32,34,39,40 the average success rate being
79 ± 16%.3,28,31,32,34,39,40 The average success rate of the
self-canalith repositioning procedure is 93 ± 4%.33,34
The short-term success rate of the Brandt-Daroff exercises varies between 24% within 1 week and 97% within 6 weeks.31,13 The Brandt-Daroff exercises are less
favored because they are slower to cure BPPV than the
other maneuvers, and there is a greater chance of canal
conversion. If patients are not treated, symptoms will
spontaneously resolve within 7 days in 30% of
patients with PC-BPPV and 53% of patients with
HC-BPPV.12 This suggests that the success rates of the
maneuvers are due to the effects of the maneuver, not
spontaneous resolution.
Although there are numerous articles reporting success for the maneuvers in the treatment of HC-BPPV
and AC-BPPV, there are no randomized controlled trials or controlled before-and-after trials for these procedures. The general consensus at this writing is that the
maneuvers for HC-BPPV are better than no treatment,
but also that they are slower to work and less reliable
than the maneuvers for PC-BPPV. There is presently no
consensus regarding treatment of AC-BPPV. However,
we believe that they make sense from a biomechanical
perspective, and there is anecdotal evidence of effectiveness. We presently feel that the maneuvers are worthwhile attempting in a symptomatic patient.
CONCLUSION
To effectively treat BPPV, the canal involved needs to be
identified with positional maneuvers. Based on the findings of the positional testing, the canal identified may be
treated with the appropriate repositioning maneuver. ✧
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The authors report no relevant financial relationships.
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Annals of Long-Term Care / Volume 15 , Number 6 / June 2007