Synonyms: include benign positional paroxysmal vertigo

Benign positional vertigo (BPV) is the most common cause of vertigo which is experienced as the illusion of movement.
Symptoms are due to inner ear dysfunction. Otoliths become detached from the maculae (the utricle based receptor for detecting head position and movement) into the semicircular canals. These are affected differentially due to anatomy:

• Posterior semicircular canal - 85-95% patients.
• Inferior semicircular canal - 5-15% patients.
• Anterior semicircular canals - very rare.

Hair cells embedded in otoliths are stimulated as they are pulled/pushed by the flow of endolymph through the semicircular canals following head movement and terminate as movement ceases. Detached otoliths may continue to move after the head has stopped moving and vertigo results from the conflicting sensation of ongoing movement with other sensory inputs.

Most BPV is idiopathic. Causes can be attributed in about 40% and include:

• Head injury.
• Spontaneous degeneration of the labyrinth.
• Post viral illness (viral neuronitis).¹
• Complication of stapes surgery.
• Chronic middle-ear disease.

Epidemiology

Benign positional vertigo (BPV) is common. A German study suggests a lifetime prevalence of 2.4%, and previous year prevalence of 1.6%.²

Risk factors³

• Older age - onset most common between 40 and 60 years.
• More common in women (male:female ratio 1:2).
• Ménière's disease (co-diagnosis in up to 30%).
• Migraine, particularly in children.⁴

Presentation⁵

History

• Sufferers endure episodes of vertigo provoked by head movements (such as entailed in rolling over in bed, lying down, sitting up, leaning forward or turning the head in a horizontal plane).
• Patients often volunteer that symptoms are worse when the head is tilted to one particular side.
• Attacks are of sudden onset and usually last 20-30 seconds with rapid resolution if the head is kept still.
• There is normally a brief latent period (usually about 5 seconds but up to 20 seconds) between the provocative movement and the experience of vertigo.
• Vertigo is usually too brief to cause vomiting, although patients sometimes complain of feeling nauseous whilst symptomatic.
• Symptoms are typically worse in the mornings.
• Associated symptoms such as hearing loss, tinnitus, ear or mastoid pain, headache, and photophobia point towards alternative diagnoses.

Examination

Clinical examination should include:

• Assessment of the external ear and tympanic membrane (excluding cholesteatoma and vesicles suggestive of Ramsay Hunt's syndrome).
• Cranial nerve examination for evidence of palsies and hearing loss.
• Diagnosis of posterior canal benign positional vertigo (BPV) can be confirmed clinically by the use of a provocation test, known at the Dix-Hallpike test.⁶ (This should be avoided in patients with neck- or back-related pathology such as cervical stenosis, severe rheumatoid arthritis, spinal cord injury, carotid stenosis or vertebral artery disease).
  • Warn the patient that transient vertigo may occur in any position.
  • Ask the patient to keep their 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 their head turned 45° to the left to test the left posterior canal. With their 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 seconds) and then return the patient to the upright position.
  • Repeat with the head turned to the right to test the right posterior canal.
  If positive:
  • The patient experiences vertigo and rotary nystagmus (best seen by looking at scleral vessels and radial markings on the iris) in posterior canal BPV. Purely horizontal nystagmus suggests horizontal canal BPV.
  • A short latency period of a few seconds should be expected.
  • Nystagmus (fast component) will be upbeat and in the direction of the undermost (affected) ear. This has a limited duration, lasting <30 seconds (adaption).
  • On sitting, there is more vertigo, experienced as the room spinning in the opposite direction (with reversal of the nystagmus).
  Generally with BPV, only one side should test positive during the Dix-Hallpike test. See reference for illustration of the Dix-Hallpike test and its interpretation.⁷ Bilateral posterior semicircular canal BPV is possible but unlikely and points towards horizontal canal involvement, vestibular neuritis or a central cause. Central positional nystagmus tends to persist whilst the provoking position is maintained (not adapting with time) and is not as direction specific as BPV, beating in any direction.

Differential diagnosis

Conditions causing vertigo and nystagmus including:

• Acute vestibular labyrinthitis.
• Multiple sclerosis.
• Ménière's disease.
• Cerebrovascular disease - transient ischaemic attack (TIA), stroke.
• Posterior cranial fossa tumours, e.g. acoustic neuroma.
• Brainstem lesions.
• Otosclerosis.
• Vertebrobasilar insufficiency.
• Iatrogenic, e.g. a side-effect of some anticonvulsant and antihypertensive medication.

Investigations

There are no current investigations that will demonstrate otoliths. Further investigation is not required where features are typical of benign positional vertigo (BPV); however, neuroimaging (CT or MRI scan) is indicated where there is diagnostic uncertainty. One study suggested a higher risk of unexpected intracranial pathology where there was no response to the initial Epley manoeuvre and in those with asymmetric hearing.⁸

Management⁵

General⁹

Where benign positional vertigo (BPV) has been diagnosed as the case of a patient's vertigo:

• Advise that symptoms are usually self-limiting over several weeks but may recur.
• Limit symptoms by getting out of bed slowly and reducing head movements.
• Offer a period of observation or immediate treatment (usually the Epley manoeuvre or Brandt-Daroff exercises).
• Consider safety:
  • DVLA advice is to avoid driving when dizzy or likely to experience an attack of vertigo whilst driving.
  • Advise the patient to inform employers where vertigo may pose an occupational hazard (e.g. working at heights, with machinery, driving).
  • Discuss measures to reduce the risk of falls.
• Follow-up at 4-6 weeks to check symptom resolution.
• Referral to a specialist where:
  • The Epley manoeuvre cannot be provided in local primary care.
  • The Epley manoeuvre has been performed and repeated without symptoms abating.
  • The diagnosis is not certain.
  • There have been more than 3 recurrences of vertigo.

Repositioning techniques

Epley manoeuvre: this is the most widely used repositioning manoeuvre for BPV. Its aim is to reposition otoliths back into the utricles from the posterior semicircular canals. Systematic review evidence supports its usefulness aiding short-term resolution of symptoms (number needed to treat 2-4).^10,11 In a 5-year follow-up study from treatment with the Epley manoeuvre, only 7% had had a severe recurrence of their BPV, sufficient to seek medical attention.¹² However, it is unclear how this compares with the natural history of untreated disease.

To perform the Epley manoeuvre:¹³

• Sit the patient upright on the couch with their head turned 45° to the affected side (the side that tested positive using the Dix-Hallpike test).
• Place your hands on either side of the patient's head and guide the patient down to lying with the head dependent (the same as in the Dix-Hallpike test).
• Rotate their head 90° to the opposite side with the patient's face upward with the head remaining dependent.
• Roll the patient on to their side whilst holding their head in this position and then rotate the head so that it is facing downward (tell the patient to look to the ground).
• Sit the patient up while maintaining head rotation.
• Simultaneously rotate the head to a central position. (There should be no nystagmus by this stage, if the procedure has been successful, as the otoliths should by now be repositioned.)

See reference for video illustration of the Epley manoeuvre.⁷

For success:

• Whilst dependent, the head should be hanging over the edge of the couch at full neck extension. If a patient is unable to tolerate this, a couch can be used in the Trendelenburg position to simulate it.
• Each position should be maintained until full resolution of symptoms and nystagmus has been achieved for at least 30 seconds.
• Some contend that a period of postural restriction (e.g. upright head posture for 48 hours, avoiding lying on affected side for 7 days) also increases success rate but there is limited evidence supporting the use of post-treatment activity restriction.¹⁴

Symptoms can improve quickly following treatment, but full recovery can take days to several weeks. If symptoms have not settled by a week and the diagnosis of BPV is highly likely, consider repeating the Epley manoeuvre.¹⁵

There are also repositioning manoeuvres for horizontal canal BPV (the 'barbecue' manoeuvre) and for anterior canal BPV.

Modified Epley manoeuvre: this can be taught to patients to perform at home (using a pillow to support the shoulders, with the head resting on the bed, rather than over the side of the bed). The supine positions are maintained for 30 seconds and the sitting upright positions for 1 minute. Typically, 3 cycles are performed just prior to going to sleep. It is thought to be helpful in patients who do not respond swiftly to therapist-led procedures, or in those who have frequent recurrence of vertigo, and has been used post-standard Epley manoeuvre with the aim of improving outcomes.¹⁶

Brandt-Daroff exercises: these were developed as a series of home exercises to loosen and disperse inner ear debris. Tell the patient to:

• Sit on the side of bed with their head rotated 45° to one side.
• Close eyes to minimise vertigo.
• Quickly lie down to the opposite side until the head touches the bed (if the head is turned to the left, lie on the right side), nose up and lateral occiput resting on the bed.
• Stay in this position for 30 seconds then sit up.
• Turn head to the other side and repeat on the opposite side.
• One session should include 6 repetitions to each side, repeat three times daily until free of vertigo for at least 48 hours.

Complications of repositioning manoeuvres included vomiting, fainting, and intolerable vertigo. Manoeuvres may be difficult in elderly or less mobile patients but they remain the most effective treatment available.¹⁷ Contra-indications are as for the Dix-Hallpike test (see above). Where symptoms persist despite attempts at repositioning manoeuvres, referral for further investigation and specialist re-evaluation should not be delayed.

Vestibular rehabilitation

A series of exercises is taught where the head is positioned deliberately to provoke vertigo, with the aim of allowing the brain to adapt and recalibrate. They are often poorly tolerated and are less effective than canalith repositioning. They are considered less effective in the short-term than repositioning techniques so are not used first-line.¹⁸

Drug treatment

Avoid vestibular suppressant medications due to lack of evidence supporting their effectiveness, risk of side-effects and possible delayed central nervous system compensation. The exception is the short-term use of antiemetics for vomiting during an acute attack.

Surgery

Surgery is very much regarded as a last resort for intractable symptoms¹⁹ - denervating the posterior semicircular canal or obliterating it by laser (transmastoid) - but deafness is a risk.

Prognosis

The natural history for benign positional vertigo (BPV) is for spontaneous remission but with a high chance of recurrence (approximately 50% at 5 years).² Where the posterior semicircular canal is involved, approximately a third of patients' symptoms will remit within a week compared with a half of those with horizontal semicircular canal involvement, related to ease of self-clearing of debris into the utricle.²⁰

BPV is considered 'benign' but may increase the risk of falls and injuries, make some occupations impossible (e.g. airline pilot²¹), and frequent episodes of vertigo may diminish quality of life, so it should be treated actively.

Document references

1. Gacek RR; Evidence for a viral neuropathy in recurrent vertigo. ORL J Otorhinolaryngol Relat Spec. 2008;70(1):6-14; discussion 14-5. Epub 2008 Feb 1. [abstract]
2. von Brevern M, Radtke A, Lezius F, et al; Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007 Jul;78(7):710-5. Epub 2006 Nov 29. [abstract]
3. Parnes LS, Agrawal SK, Atlas J; Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003 Sep 30;169(7):681-93. [abstract]
4. Ralli G, Atturo F, de Filippis C; Idiopathic benign paroxysmal vertigo in children, a migraine precursor. Int J Pediatr Otorhinolaryngol. 2009 Dec;73 Suppl 1:S16-8. [abstract]
5. No authors listed; Management of benign paroxysmal positional vertigo. Drug Ther Bull. 2009 Jun;47(6):62-6. [abstract]
6. Lempert T, Gresty MA, Bronstein AM; Benign positional vertigo: recognition and treatment. BMJ. 1995 Aug 19;311(7003):489-91.
7. Clinical Management of dizziness and vertigo, Imperial College of Medicine; Video clips illustrating the assessment and treatment of vertigo
8. Young O, Sheahan P, Rawluk D, et al; Should patients with benign positional vertigo be imaged? Ir Med J. 2007 Sep;100(8):553-4. [abstract]
9. Vertigo, Clinical Knowledge Summaries (April 2010)
10. Hilton M, Pinder D; The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2004;(2):CD003162. [abstract]
11. Helminski JO, Zee DS, Janssen I, et al; Effectiveness of particle repositioning maneuvers in the treatment of benign Phys Ther. 2010 May;90(5):663-78. Epub 2010 Mar 25. [abstract]
12. Rashad UM; Long-term follow up after Epley's manoeuvre in patients with benign paroxysmal J Laryngol Otol. 2009 Jan;123(1):69-74. Epub 2008 May 20. [abstract]
13. Chang AK; Benign Positional Vertigo, eMedicine, Aug 2009; Includes video clips illustrating Hallpike and Epley manoeuvres
14. Fyrmpas G, Rachovitsas D, Haidich AB, et al; Are postural restrictions after an Epley maneuver unnecessary? First results of a Auris Nasus Larynx. 2009 Dec;36(6):637-43. Epub 2009 May 1. [abstract]
15. Bhattacharyya N, Baugh RF, Orvidas L, et al; Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl 4):S47-81. [abstract]
16. Sommer D; Self treatment after Epley procedure was effective for benign paroxysmal positional vertigo of the posterior semicircular canal. Evid Based Med. 2006 Jun;11(3):78.
17. Clinch CR, Kahill A, Klatt LA, et al; Clinical inquiries. What is the best approach to benign paroxysmal positional J Fam Pract. 2010 May;59(5):295-7. [abstract]
18. Hillier SL, Hollohan V; Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005397. [abstract]
19. Leveque M, Labrousse M, Seidermann L, et al; Surgical therapy in intractable benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2007 May;136(5):693-8. [abstract]
20. Imai T, Ito M, Takeda N, et al; Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo. Neurology. 2005 Mar 8;64(5):920-1. [abstract]
21. Sen A, Al-Deleamy LS, Kendirli TM; Benign paroxysmal positional vertigo in an airline pilot. Aviat Space Environ Med. 2007 Nov;78(11):1060-3. [abstract]

Internet and further reading

• Rabie AN et al; Canalith-Repositioning Maneuvers, eMedicine, Jan 2010
• Bhattacharyya N, Baugh RF, Orvidas L, et al; Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl 4):S47-81. [abstract]
• Labuguen RH; Initial evaluation of vertigo. Am Fam Physician. 2006 Jan 15;73(2):244-51. [abstract]
• Swartz R, Longwell P; Treatment of vertigo. Am Fam Physician. 2005 Mar 15;71(6):1115-22. [abstract]
• Seemungal BM; Neuro-otological emergencies. Curr Opin Neurol. 2007 Feb;20(1):32-9. [abstract]

Acknowledgements