Benign Paroxysmal Positional Vertigo (BPPV)

How BPPV happens

The inner ear contains two balance systems. The utricle senses gravity and straight-line movement using tiny calcium carbonate crystals called otoconia (ear rocks). The three semicircular canals sense rotation using fluid that moves when you turn your head.

In BPPV, otoconia break loose from the utricle and drift into a semicircular canal, most often the posterior canal, which is the lowest when lying down. When you move your head, the crystals roll through the canal and drag fluid with them, sending a false "spinning" signal to the brain. When the crystals settle, the vertigo stops.

• Canalithiasis: free-floating crystals in the canal (most common).
• Cupulolithiasis: crystals stuck to the sensor (cupula), causing longer spells.

Symptoms

• sudden spinning vertigo triggered by head movement: lying down, rolling over in bed, getting up, tilting the head back to look up, or bending over
• spells lasting seconds and usually under 1 minute
• nausea, sometimes vomiting
• feeling off-balance or lightheaded between spells
• spells that cluster over days to weeks, then may go away and come back months or years later

BPPV does not cause hearing loss, ringing in the ear, headache, weakness or numbness. These suggest another cause.

Causes and risk factors

• No clear cause in about half of cases, often with age-related weakening of the inner ear
• Head injury, including minor bumps and whiplash; can affect both ears
• Inner ear disorders: vestibular neuritis, Meniere's disease
• Long periods lying flat: after surgery, at the dentist or hairdresser
• Osteoporosis and low vitamin D, linked to recurrent BPPV
• Migraine

BPPV vs other causes of vertigo

How BPPV is diagnosed

The diagnosis is made in the clinic by reproducing the vertigo.

• Dix-Hallpike test: you sit on the exam table with your head turned 45 degrees to one side, then are lowered quickly onto your back with the head tilted slightly below the table edge. If BPPV is present in the posterior canal on that side, vertigo starts after a few seconds and the eyes show a characteristic twisting, upbeating jerk (nystagmus) that fades within a minute.
• Supine roll test: turning the head side to side while lying down to check the horizontal canal.

Scans and blood tests are not needed for typical BPPV. Imaging is reserved for atypical findings or neurological signs.

Treatment: the Epley maneuver

Canalith repositioning procedures guide the crystals out of the canal and back into the utricle, where they cause no symptoms. For the posterior canal, the Epley maneuver is standard. A clinician:

1. sits you up with your head turned 45 degrees toward the affected ear
2. lays you back quickly with the head slightly extended, and waits 30 to 60 seconds
3. turns your head 90 degrees to the other side, waiting again
4. rolls you onto your side so you look toward the floor, waiting again
5. brings you back to sitting

It cures about 80 percent of people after one or two treatments. The Semont maneuver is an alternative. Horizontal canal BPPV is treated with different maneuvers, such as the barbecue roll or Gufoni maneuver.

Home exercises

Your clinician may teach you to do the Epley maneuver at home for recurrences, once the affected side is confirmed. Doing it on the wrong side can make symptoms worse, so learn it in person first. Brandt-Daroff exercises are less effective but sometimes used.

What does not help

Medicines such as meclizine (antihistamines) and benzodiazepines do not cure BPPV. Guidelines advise against using them routinely; they may help briefly for severe nausea during treatment. Activity restrictions after the maneuver are not usually needed.

Surgery

Rarely, for persistent, disabling BPPV that does not respond to many maneuvers, a surgeon can plug the affected canal.

Recovery and recurrence

Most people feel better immediately or within a few days of repositioning, though a vague unsteadiness can linger for a week or two. BPPV recurs in about a third to a half of people within 5 years. Older adults should be checked for fall risk. Some evidence suggests vitamin D supplements may reduce recurrence in people with low levels.

Frequently asked questions

What triggers BPPV vertigo?

Changes in head position relative to gravity trigger it: lying down, rolling over in bed, getting out of bed, looking up at a high shelf, or bending forward. The spinning starts after a few seconds and stops within a minute.

How long does BPPV last?

Each spell lasts seconds to less than a minute. Without treatment, the condition itself may resolve in weeks to months as the crystals dissolve, but repositioning maneuvers usually cure it in one or two sessions. It can come back later.

Can I do the Epley maneuver at home?

Yes, once a clinician has confirmed which ear is affected and shown you how. Doing it on the wrong side can make vertigo worse. If symptoms persist after a few attempts, or you have other symptoms, see your doctor.

Is BPPV dangerous?

BPPV itself is harmless, but sudden vertigo can cause falls, especially in older adults. Vertigo with speech, vision or coordination problems, or that is constant, is not typical of BPPV and needs emergency assessment for stroke.

Does BPPV cause hearing loss?

No. BPPV affects only the balance system. If vertigo comes with hearing loss, ringing or ear fullness, another condition such as Meniere's disease or labyrinthitis is more likely and needs evaluation.