Direct answer
BPPV is a common inner-ear cause of positional vertigo. Tiny calcium-carbonate crystals displaced from the utricle enter a semicircular canal and create a false balance signal when the head moves. This produces brief spinning after rolling in bed, sitting up, bending or looking upward. Symptoms alone do not confirm the diagnosis: the affected canal should be identified with positional testing and treated with a canal-specific repositioning manoeuvre.
Symptoms
- Spinning when rolling in bed, sitting up, bending or extending the head
- Each triggered burst usually lasts seconds and less than one minute
- Nausea and occasionally vomiting
- Mild residual unsteadiness or fear of falling between attacks
- Rapid improvement in the intense spinning once the head is still
Possible causes
- No specific cause in many cases
- Age-related loosening of otoconia
- A previous head injury
- Following vestibular neuritis or another inner-ear illness
- Sometimes after prolonged bed rest or surgery
- A previous episode, because BPPV can recur
How it is assessed
- Clarify timing, triggers, episode duration, hearing symptoms, headache and neurological symptoms
- Assess spontaneous and gaze-evoked eye movements, balance, gait and perform focused ear or neurological examination as needed
- Use the Dix–Hallpike test to look for characteristic positional nystagmus in suspected posterior-canal BPPV
- Consider the supine roll test when the history fits BPPV but Dix–Hallpike shows horizontal or no nystagmus
- Avoid routine imaging in typical BPPV; use targeted tests or imaging for atypical patterns, focal neurological signs, sudden hearing loss or concern for another diagnosis
Treatment options
- A canalith-repositioning procedure—commonly the Epley manoeuvre—for the affected posterior canal is first-line treatment
- Use a different canal-specific repositioning manoeuvre for horizontal- or anterior-canal disease
- Selected patients may use a home manoeuvre after instruction and confirmation of the side, canal and relevant neck or back limitations
- Do not routinely treat BPPV with prolonged antihistamines or vestibular suppressants; a clinician may consider brief symptomatic relief for severe nausea
- Use vestibular rehabilitation for persistent imbalance or fall risk when appropriate
- Reassess within one month; persistent symptoms need evaluation for unresolved BPPV or another vestibular or neurological disorder
When to seek emergency care
- Facial droop, limb weakness or numbness, or slurred speech
- Double vision, severe new imbalance or inability to stand or walk unaided
- A new severe headache, fainting or seizure
- New one-sided hearing loss or persistent vertigo with auditory symptoms
- Severe continuous vertigo lasting hours rather than brief position-triggered spells
- Recent head injury, chest pain, an irregular heartbeat or repeated falls
At a glance
Definition: Brief, intense spinning after rolling in bed, looking up or bending may be BPPV. It occurs when tiny calcium crystals move into the wrong semicircular canal; an appropriate positional test and canalith-repositioning manoeuvre can relieve symptoms for many patients.
Key takeaways
- Vertigo is reliably triggered by particular head movements
- Intense spinning usually lasts seconds and less than one minute
- Nausea or short-lived unsteadiness may follow an episode
- New hearing loss, fainting or a persistent neurological deficit is not typical of uncomplicated BPPV
Clinical steps
- Use the history and eye movements to identify the affected side and canal
- Perform the Dix–Hallpike test for suspected posterior-canal BPPV
- Use a supine roll test when horizontal-canal BPPV is possible
- Offer an Epley or another canal-specific repositioning manoeuvre, followed by review
Red flags: Do not assume BPPV if dizziness occurs with facial droop, limb weakness or numbness, slurred speech, double vision, inability to stand, a new severe headache, fainting or new hearing loss. Seek emergency assessment.
How I assess this in clinic
BPPV cannot be diagnosed from the word ‘dizziness’ alone. I first clarify the trigger, duration, movement pattern and whether hearing or neurological symptoms accompany it.
In typical posterior-canal BPPV, the Dix–Hallpike test provokes characteristic vertigo and nystagmus. A horizontal-canal pattern may require the supine roll test.
When diagnostic criteria for typical BPPV are met, routine CT, MRI and laboratory testing are usually unnecessary. Atypical findings or concern for another condition call for targeted investigation.
An internet manoeuvre may not help when the side or canal is wrong and may be unsuitable with some neck, back or vascular problems. Seek a trained assessment for a first episode, uncertain diagnosis or any red flag.
Frequently asked questions
How long does BPPV spinning last?+
The intense spinning triggered by a particular head movement usually lasts seconds and less than one minute. Nausea or imbalance can linger. Continuous vertigo lasting much longer requires assessment for other causes.
Is BPPV a stroke?+
BPPV is not a stroke. However, weakness, numbness, slurred speech, double vision, a new severe headache or inability to stand with dizziness requires urgent assessment for stroke and other central causes.
Does BPPV require a CT or MRI scan?+
Routine imaging is generally unnecessary when the history and positional nystagmus meet typical BPPV criteria. Imaging may be appropriate for atypical findings, neurological signs, sudden hearing loss or concern for another diagnosis.
Is the Epley manoeuvre safe to do at home?+
Many patients can do it after the affected side and canal are confirmed and they receive instruction. Do not self-treat an uncertain diagnosis or significant neck, back, vascular or mobility problem without clinical advice.
Will vertigo medicine cure BPPV?+
Vestibular suppressants do not move the crystals back and are not recommended as routine long-term BPPV treatment. A canal-specific repositioning manoeuvre is the main treatment; brief symptom relief may be considered separately for severe nausea.
Can BPPV come back?+
Yes. Recurrence is possible after successful treatment. Seek reassessment if positional vertigo returns, and emergency care if new neurological or hearing red flags appear.
Related ENT services
Vertigo & BalanceSpinning or imbalance can arise from the inner ear and other causes; careful history and examination are essential.→Ear ConditionsAssessment of ear pain, infection, eardrum perforation, tinnitus, cholesteatoma and hearing loss.→Hearing TestsAge- and symptom-appropriate tests help identify the type and degree of hearing loss.→For patient education; not a substitute for individual diagnosis or treatment. Seek emergency care for red-flag symptoms.