Disorders · Introduction
Benign paroxysmal positional vertigo
The commonest cause of vertigo — and one of the few you can diagnose with certainty and cure at the bedside in minutes. A mechanical problem of loose inner-ear crystals, recognised by its pattern and confirmed by a positional test.
What BPPV is
BPPV causes brief spinning when you move your head a certain way — rolling over in bed, lying down, looking up. Each spell lasts well under a minute. It happens because tiny crystals (otoconia) that normally sit in one part of the inner ear come loose and fall into a balance canal, where they make the canal react to gravity. There is no hearing loss or ringing.
The name decodes the disease: benign (non-sinister, self-limiting), paroxysmal (sudden, brief), positional (provoked by head position relative to gravity). It is a mechanical disorder — canalithiasis or cupulolithiasis — not an inflammatory or neurodegenerative one, and characteristically lacks cochlear symptoms.1
BPPV is the prototype of bedside-diagnosable, mechanically-treatable vertigo: history plus a positional test localises the canal and side, and a repositioning manoeuvre resolves it without imaging or drugs in the great majority.2,5 The clinician’s task is to recognise the pattern, localise precisely, and screen out the central mimics that masquerade as positional vertigo.
BPPV by the numbers
BPPV accounts for a large share of vertigo seen in dizziness clinics, skews female, and climbs steeply with age. The posterior canal is involved in the great majority of cases.3,4
Which canal?
share of BPPV cases- Posterior canal — 80–90%
- Horizontal canal — 5–15%
- Anterior canal — 1–2%
How this chapter is organised
- Pathophysiology & causes — canalithiasis vs cupulolithiasis, which canal, and why BPPV happens.
- Clinical features — the pattern: brief, latent, fatigable, no cochlear symptoms.
- Diagnosis & positional tests — the Dix–Hallpike and supine roll test, with an interactive simulator and a nystagmus classifier.
- Differential diagnosis — telling BPPV from vestibular migraine, Ménière’s, neuritis and central causes.
- Treatment & prognosis — principles, recurrence, and when to escalate.
Treatment manoeuvres are covered in depth, by canal and with step-by-step animations, in the Therapeutic Manoeuvres chapter.
Key points
- BPPV is the commonest cause of vertigo — mechanical, benign, and highly treatable.
- Brief positional vertigo with latency and fatigability, and no hearing loss or tinnitus.
- Posterior canal dominates (80–90%); horizontal 5–15%; anterior 1–2%.
- Diagnosis is clinical: history + positional test localise the canal and side.
- Always exclude central mimics before attributing positional vertigo to BPPV.