Benign paroxysmal positional vertigo


Exterior of labyrinth of the inner ear.
  • Abbreviation: BPPV
  • Due to canalolithiasis (migration of otoconia into one of the semicircular canals)
  • Mean age is mid-50s; women are twice as likely to be affected as men
  • Mean duration is 2 weeks

Clinical Features

  • Sudden-onset vertigo and associated nystagmus precipitated by head movements
    • Latency period <30s between provocative head position and onset of nystagmus
    • Intensity of nystagmus increases to a peak before slowly resolving
    • Duration of vertigo and nystagmus ranges from 5–40s
    • Repeated head positioning causes vertigo and nystagmus to fatigue and subside
    • Nystagmus reverses direction during the head down and head up portions of Dix-Hallpike
  • Nausea/vomiting common
  • Symptoms worse in the morning (symptoms fatigue as day goes on)
  • No associated hearing loss or tinnitus
  • MUST distinguish from central vertigo (HINTS Exam, Cerebellar stroke)

Differential Diagnosis



See vertigo for a general approach

Dix-Hallpike Maneuver

  • 50-85% Sensitive for BPPV[1]
  • Do not attempt provocative maneuvers if the patient is symptomatic with nystagmus at rest


  • Patient sits upright
  • Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
  • Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
  • Observe the eyes for 45 seconds for nystagmus. There is often 15 seconds of latency prior to symptoms.
    • Immediate symptoms requires consideration for central etiology
  • A positive test for BPPV is evidenced by the rotational (torsional) nystagmus
    • Fast phase of the rotatory nystagmus is toward the affected ear (geotropic nystagmus), which is the ear closest to the ground
    • Rotational nystagmus away from affected ear (ageotropic nystagmus) requires consideration for central lesion



Epley Maneuver[3]

Epley manuver
  • Epley begins after the last step of the Dix Hallpike
  • Patient remains in the position with exacerbated nystagmus for approximately 1–2 minutes.
  • Patient's head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground
    • Maintain the 20 degree neck extension
  • Keep the head and neck in a fixed position while the patient rolls onto their opposite shoulder. The patient is now looking downwards at a 45 degree angle.
  • Keep the patient in the new position for 1 minute.
  • Finally bring the patient up to sitting while holding the head in 45 degree rotation.
  • May require multiple attempts, but you can discharge patient home with daily exercises
    • Improvement after x1 in 47% of patients, after x2 an additional 16%, and after x3 an additional 21%[4]

Medical management


  • Consider referral to ENT for persistent symptoms despite treatment

See Also

External Links


  1. Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81
  2. Humphriss, Rachel; Baguley D; Sparks V; Peerman S; Mofat D (2003). "Contraindications to the Dix-Hallpike manoeuvre : a multidisciplinary review". International Journal of Audiology 42 (3): 166–173.
  3. Hilton, Malcolm P; Pinder, Darren K (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". In Hilton, Malcolm P. Cochrane Database of Systematic Reviews
  4. Hughes D, Shakir A, Goggins S, et al. How many Epley manoeuvres are required to treat benign paroxysmal positional vertigo? J Laryngol Otol. 2015; 129(5):421-424.