Practice
Diagnostic-to-treatment algorithm
A disciplined sequence — history, positional testing, canal-specific treatment, reassessment — turns BPPV from a confusing complaint into a curable, one-visit problem, while keeping central mimics in view throughout.
Brief positional vertigo · triggers on rolling, looking up, lying down
1 · History and initial screening
Classic BPPV is brief, recurrent positional vertigo lasting seconds to minutes, triggered by rolling in bed, looking up or leaning forward. Such positional triggers strongly suggest a peripheral origin. The history also begins to localise the canal: posterior-canal vertigo is provoked by lying down or rolling; horizontal-canal vertigo is more intense and horizontal-roll triggered; anterior-canal BPPV is suspected when testing induces downbeat vertigo.
2 · Positional testing to localise the canal
- Posterior canal — the Dix–Hallpike remains the gold standard, producing torsional-upbeat nystagmus lasting under 60 seconds.1
- Horizontal canal — the supine roll test elicits horizontal nystagmus and separates geotropic (canalithiasis) from apogeotropic (cupulolithiasis) forms.
- Anterior canal — the straight head-hanging test is preferred, eliciting downbeat nystagmus consistent with anterior-canal involvement.
In acute vestibular syndrome, use bedside tests — HINTS and the video head impulse test — to exclude central causes. A normal head impulse, direction-changing nystagmus or vertical skew all warrant urgent neuroimaging.2
3 · Canal-specific repositioning
- Posterior canal — Epley first-line; Semont an effective alternative, especially with cervical limitation.
- Horizontal canal — for geotropic forms, Gufoni or Lempert; apogeotropic forms may need a Casani/Zuma to address cupulolithiasis first.
- Anterior canal — Yacovino first-line for non-lateralising BPPV; deep head-hanging if not tolerated or ineffective.
4 · Reassessment and retreatment
Review within 5–7 days. If symptoms persist, repositioning can be repeated or adapted: posterior-canal manoeuvres up to three times before reconsidering the diagnosis; horizontal canal alternating Gufoni and Lempert, or adding forced prolonged positioning; anterior canal repeating Yacovino or deep head-hanging. Routine post-manoeuvre postural restrictions are not required.3
5 · Red flags and escalation
Remain alert for warning signs that indicate serious pathology: vertical or direction-changing nystagmus on positional testing, neurological symptoms such as dysarthria or limb ataxia, and persistent symptoms despite multiple appropriate manoeuvres. Any of these warrants MRI with diffusion-weighted imaging to exclude posterior-circulation stroke, cerebellar tumour or demyelination.4
The algorithm in one line
- History → positional test (Dix–Hallpike / supine roll / head-hanging) → localise canal & side.
- Exclude central mimics with HINTS / vHIT in acute vestibular syndrome.
- Treat by canal → reassess at 5–7 days → repeat or adapt.
- Red flags or refractory symptoms → MRI-DWI and neuro-otology referral.