Brief positional vertigo from displaced otoconia in a semicircular canal; treat with canalith repositioning.
Also known as: BPPV, benign paroxysmal positional vertigo, positional vertigo, canalithiasis
Overview
Common peripheral vestibular disorder characterized by brief episodes of vertigo provoked by changes in head position relative to gravity, caused by displaced otoconia (calcium carbonate crystals) within a semicircular canal — most commonly the posterior canal.
Epidemiology
Most common cause of vertigo overall. Lifetime prevalence ~2.4%. Incidence increases with age; women > men by ~2:1. Peak in 5th-7th decade.
🔒 Free preview limit reached
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Benign Paroxysmal Positional Vertigo (BPPV) outline — plus all 514 diagnoses, 3,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
Osteoporosis / vitamin D deficiency (otoconia metabolism)
Migraine
Recent ear surgery
Pathophysiology
Otoconia detach from the utricular macula and migrate into a semicircular canal (~85-95% posterior, ~5-15% horizontal, rare anterior). Canalithiasis: free-floating debris moves with head position changes, producing endolymph flow that deflects the cupula and triggers vertigo (latency, brief duration). Cupulolithiasis (less common): otoconia adhere to the cupula, producing sustained nystagmus while the head is in the provoking position.
Clinical presentation
Symptoms
Brief (<60 seconds) episodes of true vertigo triggered by changes in head position: rolling over in bed, getting in/out of bed, looking up, bending forward
Nausea, occasionally vomiting
Postural unsteadiness between episodes (often described as 'cloudy head' or 'off-balance')
No hearing loss, tinnitus, or other otologic symptoms
No neurologic deficits (no diplopia, dysarthria, weakness, sensory loss)
Episodes recur over days to weeks; spontaneous remission common but recurrence rate ~30-50% at 5 years
Signs / physical exam
Posterior canal BPPV: Dix-Hallpike maneuver produces upbeat-torsional nystagmus (geotropic — torsional component toward the affected ear) after ~5-15 second latency, lasting <60 seconds, with fatigability on repetition
Horizontal canal BPPV: supine head-roll test (Pagnini-McClure) produces direction-changing geotropic (canalithiasis) or apogeotropic (cupulolithiasis) horizontal nystagmus
Normal neurologic exam between maneuvers — no focal weakness, sensory loss, ataxia, or cerebellar signs
Normal hearing on bedside testing
Classic findings
Dix-Hallpike maneuver provoking transient upbeat-torsional nystagmus with concurrent vertigo, latency, and fatigability.
Differential diagnosis
Vestibular neuritis / labyrinthitis — Continuous (not positional) vertigo lasting days, severe, often after viral illness; horizontal nystagmus that does not change direction; labyrinthitis adds hearing loss
Meniere disease — Episodic vertigo lasting minutes to hours + low-frequency sensorineural hearing loss + tinnitus + aural fullness
Vestibular migraine — Recurrent episodes of vertigo with or without headache + history of migraine + photo/phonophobia; lasts 5 min to 72 h
Posterior circulation stroke / TIA (PICA, AICA, basilar) — RED FLAG: vertigo with neurologic signs — diplopia, dysarthria, dysphagia, ataxia, hemiparesis, central nystagmus, normal head impulse test; consider in age >60, vascular risk factors, abrupt onset; HINTS exam
Orthostatic hypotension / pre-syncope — Lightheadedness on standing (not true vertigo); BP drop documented
Diagnostic workup
Diagnostic criteria
Bárány Society criteria: characteristic positional vertigo + positional nystagmus on appropriate maneuver (Dix-Hallpike for posterior canal, head-roll for horizontal canal), with timing and direction consistent with the involved canal, and exclusion of central causes.
Labs
None routinely indicated for typical BPPV
Consider vitamin D and calcium/PTH if recurrent or suggestive history of osteoporosis
Imaging
Imaging NOT required for classic BPPV
MRI brain with brainstem/IAC views if: atypical features (continuous vertigo, neurologic findings, central nystagmus, persistent symptoms after repositioning, unilateral hearing loss, abnormal HINTS) → exclude posterior circulation stroke or cerebellopontine angle mass
HINTS exam (Head Impulse, Nystagmus pattern, Test of Skew) — in patients with acute vestibular syndrome (continuous vertigo); a 'central' HINTS pattern (normal head impulse, direction-changing nystagmus, vertical skew) is more sensitive than early MRI for posterior circulation stroke
Epley maneuver for posterior canal BPPV (success rate 60-90% per attempt; may repeat)
Semont (liberatory) maneuver — alternative for posterior canal
Lempert (BBQ roll) or Gufoni maneuver for horizontal canal BPPV
Provide patient education and at-home exercises (Brandt-Daroff exercises) for recurrence or as adjunct
Reassurance about benign nature and high spontaneous remission rate
Second-line / adjunct
Repeat maneuvers if symptoms persist or recur — referral to vestibular physical therapy
Avoid prolonged use of vestibular suppressants (meclizine, dimenhydrinate, scopolamine, benzodiazepines) — they impair central compensation; may use for short-term symptomatic relief only
Antiemetics for nausea (ondansetron, prochlorperazine — caution in elderly; promethazine)
Surgical posterior semicircular canal occlusion — rare, for severe refractory cases
If recurrent BPPV, treat underlying contributors: vitamin D supplementation if deficient (some evidence reduces recurrence), management of comorbid vestibular disorders, screen for osteoporosis
Complications
Falls and fall-related injuries, especially in elderly
Persistent positional vertigo if untreated or refractory (rare)
Anxiety, depression, fear of movement (kinesiophobia)
Reduced quality of life and limitation of activities (driving, work)
Recurrence (~30-50% within 5 years)
Conversion to another canal during maneuvers (~5%) — re-test and re-treat
PANCE pearls
BPPV is the most common peripheral cause of vertigo and responds rapidly to repositioning — definitive treatment is mechanical, not pharmacologic.
Vestibular suppressants (meclizine) treat symptoms but DELAY central compensation — use sparingly and never as primary therapy.
If Dix-Hallpike produces vertical (purely downbeat) nystagmus or other atypical patterns, suspect central cause (cerebellar or brainstem lesion).
HINTS exam in acute vestibular syndrome (continuous vertigo) — 'INFARCT' findings (Impulse Normal, Fast-phase Alternating, Refixation on Cover Test) indicate central cause and require urgent imaging.
BPPV after head trauma is often bilateral and more refractory to single repositioning attempts.
Recurrent BPPV warrants vitamin D screening — supplementation in deficient patients may reduce recurrence (Jeong J Neurol 2020).
Brandt-Daroff exercises are less effective than Epley but useful for recurrence prevention and patient self-management.
References
AAO-HNS 2017 — Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Bhattacharyya et al., Otolaryngol Head Neck Surg 2017)
AAN 2008 — Practice Parameter: Therapies for BPPV (Fife et al., Neurology 2008; reaffirmed)
Bárány Society 2015 — BPPV Diagnostic Criteria (von Brevern et al., J Vestib Res 2015)
Practice Neurology questions on FirstPassPA
Turn this outline into retention. 3,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants.