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Benign Positional Vertigo

There are attacks of sudden-onset rotational vertigo lasting >30sec provoked by head-turning. There is usually a brief latent period of a few seconds between the provocative movement and the vertigo. Patients often volunteer that symptoms are worse when the head is tilted to one particular side. Vertigo is usually too brief to cause nausea or vomiting. ¹
If any of these features are absent (eg. no latent period, vertigo produced by movement in all directions, vomiting ++) seek a central cause - particularly posterior cranial fossa disease.

Incidence 64/100,000 per year. It can occur at any age but usually <40; M:F 1:2; Common after head injury or viral neuronitis (60% cause unknown).

Diagnosis: Provocative test (Hallpike manoeuvre): ²

• Warn patient that transient vertigo may occur in any position.
• Patient should keep eyes open and stare at the examiner's nose.
• Prepare the couch so the headrest is down and the patient's head will overhang the end.
• Begin with patient sitting with head turned 45° to left to test left posterior canal. With head in this position quickly lie the patient down until the head is dependent ~30° below the level of the couch.
• Observe for nystagmus in each position (30 sec) and then return patient to upright position.
• Repeat with the head turned to the right to test the right posterior canal.

If +ve, the patient experiences vertigo and rotary nystagmus (best seen by looking at scleral vessels and radial markings on iris). Nystagmus (fast component) will beat towards the undermost ear, after a latent period of a few seconds. This lasts <1min (adaption). On sitting, there is more vertigo (± nystagmus).

Pathogenesis: Displacement of the otoconia from the maculae (the receptor for sensing acceleration in the utricle and saccule). The otoconia then settle on the lowest part of the labyrinth.

Causes: Head injury; spontaneous degeneration of the labyrinth, post viral illness or stapes surgery; chronic middle-ear disease.

Treatment

• Repeated adoption of the position which causes vertigo (habituation).
• Self guided positional exercises: One session should include 6 repetitions to each side, repeat x3 daily. Sit on side of bed with head rotated 45° to one side. Close eyes to minimise vertigo. Quickly lie down to opposite side until head touches bed (if head turned to left, lie on right side). Stay in this position for 30 seconds then sit up; turn head to other side and repeat on opposite side.
• Consider physiotherapy referral for teaching formal Epley head exercises to disperse otoconia.
• A last resort is denervating the posterior semicircular canal or obliterating it by laser (transmastoid) as an option, but deafness may follow.

References:

1. Benign Positional Vertigo; Neurological Differential Diagnosis (2nd Ed); John Patten; Springer 1996; p81-2
2. Lempert T, Gresty MA, Bronstein AM; Benign positional vertigo: recognition and treatment.; BMJ 1995 Aug 19;311(7003):489-91.

Last issued 30 Aug 2006