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Vertigo when she rolls over in bed

A 64-year-old woman with brief vertigo triggered by lying down and rolling onto her left side.

The case

A 64-year-old retired teacher presents with episodes of severe vertigo that began two weeks ago. Each episode is triggered by a specific movement — lying down at night, rolling over in bed (particularly onto her left side), and looking up at the top shelf of her bookcase. The vertigo is intense for about 15–20 seconds and then settles, leaving her with a mild sensation of unsteadiness for a few minutes.

There are no auditory symptoms. There has been no recent illness, no head injury, and no headache. She has no other neurological symptoms. Her hearing tests last year were normal.

On examination her cranial nerves, motor and sensory examinations, coordination, and gait are all unremarkable. There is no spontaneous nystagmus in primary gaze. A left Dix-Hallpike manoeuvre, performed carefully, provokes a burst of upbeating-torsional nystagmus (with the upper pole of the eye beating toward the dependent left ear) after a latency of 4 seconds, lasting approximately 25 seconds and accompanied by reproduction of her vertigo. The right Dix-Hallpike is negative.

Question

What is the diagnosis and what is the appropriate immediate management?

Teaching point

The Dix-Hallpike provokes a pathognomonic upbeating-torsional nystagmus in posterior canal BPPV: the upper pole of the eye beats toward the dependent (affected) ear, with a latency of 1–5 seconds, crescendo-decrescendo intensity, and duration under 60 seconds. Recognising the pattern means recognising the canal, the side, and the type (canalithiasis vs cupulolithiasis). Treatment is the Epley manoeuvre — five positions, each held for 30–60 seconds — and is one of the most satisfying interventions in clinical medicine.

References

  1. [1]Bhattacharyya N, Gubbels SP, Schwartz SR, et al.. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngology–Head and Neck Surgery 2017;156(3_suppl):S1–S47. doi:10.1177/0194599816689667
  2. [2]von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, Newman-Toker D. Benign paroxysmal positional vertigo: diagnostic criteria. Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research 2015;25(3–4):105–117. doi:10.3233/VES-150553
  3. [3]Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngology–Head and Neck Surgery 1992;107(3):399–404. doi:10.1177/019459989210700310
Related moduleBenign Paroxysmal Positional Vertigo →