Benign paroxysmal positional vertigo (BPPV)
Overview
Summary
Brief episodic vertigo triggered by specific head positions due to free-floating otoconia in a semicircular canal (canalithiasis) or adherent to the cupula (cupulolithiasis). The posterior canal is involved in ~85% of cases.
Diagnostic criteria
See the Bárány Society / clinical practice guideline papers[5,4] listed on the references page for the consensus diagnostic framework used in this profile.
Epidemiology
Lifetime prevalence ~2.4%. Peak in 6th–7th decades. F:M ≈ 2:1.
Pathophysiology
Dislodged otoconia from the utricular macula enter a semicircular canal. Position change produces hydrodynamic drag on the cupula (canalithiasis) or a sustained gravity-dependent deflection (cupulolithiasis), producing canal-specific nystagmus.
Prognosis
Excellent — 80% resolve with one maneuver; ~50% recur within 5 years.
Key examination findings
- ◆Dix-Hallpike: posterior canal — upbeat + ipsilateral torsional, latency 1–5 s, duration <60 s, fatigable
- ◆Supine roll test: horizontal canal — geotropic (canalithiasis) or apogeotropic (cupulolithiasis)
- ◆Between attacks: examination is normal
Investigations
- ▸Diagnosis is clinical — Dix-Hallpike + supine roll test
- ▸Imaging only if atypical features (no latency, no fatigue, persistent downbeat, central signs)
Management
- ●Posterior canal: Epley canalith repositioning (efficacy 80% first attempt)
- ●Posterior canal alternative: Semont (liberatory) maneuver
- ●Horizontal canal geotropic: barbecue (Lempert) roll or Gufoni
- ●Horizontal canal apogeotropic: Gufoni (apogeotropic) or modified Semont; may need conversion to geotropic first
- ●Vestibular rehabilitation if maneuvers fail or for residual dizziness
- ●Avoid prolonged vestibular suppressants
Clinical pearls
- ★Always test BOTH sides with Dix-Hallpike, and always supine roll test if Dix-Hallpike negative but BPPV suspected.
- ★Persistent positional nystagmus without latency or fatigue → think central positional nystagmus (cerebellar).