If you have been experiencing vertigo and done a Google Search (or two), a common condition that comes up as a cause of symptoms is benign paroxysmal positional vertigo (or BPPV). BPPV is the most frequently experienced vestibular disorder (1,2,3). BPPV has an estimated lifetime prevalence of 2.4% in the general adult population (3).

As a vestibular physiotherapist, I see folks for BPPV treatment in Toronto at my physiotherapy clinic on St Clair Avenue West between Dufferin Street and Lansdowne Avenue. 

To help you learn more about this common vestibular condition, I’ll cover the following topics: 

• What is benign paroxysmal positional vertigo?

• What causes benign paroxysmal positional vertigo?

• Why does benign paroxysmal positional vertigo happen?

• What are common symptoms of benign paroxysmal positional vertigo?

• Can benign paroxysmal positional vertigo cause headaches?

• How is benign paroxysmal positional vertigo diagnosed?

• Are there different types of benign paroxysmal positional vertigo?

• Who treats benign paroxysmal positional vertigo?

• How is benign paroxysmal positional vertigo treated?

• Can benign paroxysmal positional vertigo be cured?

• Can benign paroxysmal positional vertigo happen more than one time?

• Is there anything that I should consider changing if I’ve had BPPV?

What is benign paroxysmal positional vertigo?

BPPV is the most common vestibular condition that causes vertigo (1,2,3,4). The most reliable predictors of BPPV are finding that your symptoms are triggered by rolling in bed and that your vertigo (or dizziness spell) lasts less than a minute when it comes on (4).

What causes benign paroxysmal positional vertigo? 

Benign paroxysmal positional vertigo happens when calcium carbonate crystals (also called otoconia or canaliths) detach from the macular bed of the utricle and move into one (or more) of the semicircular canals. These crystals cause inappropriate flow of the fluid within the canal which stimulates the sensory cell (canalithiasis) or by making the sensory cell gravity-sensitive (cupulolithiasis). In both cases, the person experiencing BPPV may feel these symptoms.

Why does benign paroxysmal positional vertigo happen? 

There are a lot of theories as to why BPPV happens and what may make one person more likely to experience it than another. With folks that have primary (or idiopathic) BPPV, there is no sign of another condition causing the BPPV episode. Primary BPPV accounts for 50-70% of cases (1). 

With folks that have secondary BPPV, their condition is considered to be the result of another health condition. Secondary BPPV can be the result of head trauma and concussion, inner ear infection (vestibular neuritis or labyrinthitis), inner ear surgery, or migraine (1). In these cases, physical trauma or changes in vascular flow are thought to have led to crystals dislodging from the utricle.

Who gets benign paroxysmal positional vertigo? 

Here are things that we do know from the research that has been conducted so far: 

• Women are more likely than men to experience BPPV in their lifetime (1,3,5).

• Folks in their 5th decade of life and older were more likely to experience BPPV than younger folks (1,3). 

• Folks with osteoporosis are more at risk than those with osteopenia (5)

• Folks with vitamin D deficiency are more at risk (5). Research suggests they may also be more at risk of persistent symptoms after treatment (6) and recurrences of BPPV (7,8,9). Read more about vitamin D deficiency.

• Folks with high total cholesterol levels (5)

• Folks with a migraine history (1,5)

What are common symptoms of benign paroxysmal positional vertigo? 

Most folks will experience the following symptoms when BPPV is present: 

• Positional vertigo, although some folks will feel dizzy vs spinny (1,2)

• External vertigo, a visual sense that their environment is moving that happens while they’re feeling the internal vertigo or dizziness (2)

• Unsteadiness or a sense of being off balance (1,2)

• Nausea, and in some cases vomiting (1,2)

• Other nervous system responses: increased breathing or heart rate, sweating, feeling hot or cold (2)

Can benign paroxysmal positional vertigo cause headaches? 

While the majority of folks will experience the symptoms listed above, there are a good number of folks that experience headache during a BPPV episode. Research suggests that the common types of headache experienced are tension-type headache, migraine, and cervicogenic headache (10).

How is benign paroxysmal positional vertigo diagnosed? 

Testing to diagnose BPPV is best conducted with your vision removed. When you’re able to look at something (or visually fixate your eyes), the size of the response from the testing will be reduced and, in some cases, may make it challenging to know if the test is positive or negative.

At Wave Physiotherapy, I use video frenzel goggles with an infrared camera during testing. This allows me to get a close up view of your eye while taking you through positional testing for BPPV. During these tests, you will be asked to lie onto your back with your head partially turned and tilted back (Dix-Hallpike positional testing) and with your head turned with the head elevated (head roll testing). Each of these positions will be held at least 40 seconds to be sure that I’m able to identify whether there is a positive or negative test for each position.

During positional tests you are closely monitored for symptoms and I watch the video feed closely to see if nystagmus (rapid, involuntary eye movements) is present that identifies BPPV in the canals being tested. I’ll use these tests to diagnose which canal is affected and the type of treatment that makes the most sense to use for your specific condition.

Are there different types of benign paroxysmal positional vertigo?

BPPV is thought to have two forms: canalithiasis and cupulolithiasis. Positional testing for these two types of BPPV will show different results and this will help to guide the type of treatment maneuver that is used.

Canalithiasis is believed to occur when the canaliths within the semicircular canal are able to move freely (1). Typically there will be a delay before symptoms and nystagmus begin, with a rapid increase, then decrease in nystagmus and symptoms. It is typical for these to last less than 30 seconds, but may last up to 1 minute for some folks.

Cupulolithiasis is believed to occur when the canaliths within the semicircular canal have adhered to the cupula, the part of the canal that contains the hair cells (1). Typically nystagmus and symptom onset is immediate and last longer than 30 seconds.

Who treats benign paroxysmal positional vertigo? 

BPPV is treated by healthcare professionals that have taken additional training in the assessment and treatment of vestibular conditions. This includes medical doctors, audiologists, occupational therapists, and physiotherapists.

Wave Physiotherapy is located on St Clair Ave West between Lansdowne Ave and Dufferin St in Toronto, Ontario. I am a vestibular physiotherapist and see children and adults for BPPV treatment. 

How is benign paroxysmal positional vertigo treated? 

BPPV is treated using canalith repositioning maneuvers (also known as CRM, canal repositioning techniques, or CRT) or canalith liberatory maneuvers. These techniques use positioning and time to assist with moving the displaced crystals back toward the utricle (the part of the inner ear where these crystals came from).

Once the type of BPPV present and which canal is affected is identified, the most appropriate maneuver to use for treatment will be reviewed with you. It is important that you know what to expect during the treatment session. I will help guide you through any movements or position changes that need to happen to complete the chosen maneuver effectively.

When canalithiasis is diagnosed during the evaluation, the CRM that is chosen will be based on the affected canal. The most common treatment maneuver that will be used for posterior canal canalithiasis is the Epley maneuver and for horizontal canal canalithiasis is the BBQ roll (or barbecue roll). 

When cupulolithiasis is diagnosed during the evaluation, a liberatory maneuver will be used for treatment. The most common treatment maneuver for posterior canal cupulolithiasis is the Semont maneuver and for horizontal canal cupulolithiasis is the Casani or modified Semont maneuver.

Can benign paroxysmal positional vertigo be cured?

Benign paroxysmal positional vertigo is a mechanical issue. Often treatment with maneuvers is successful in resolving symptoms within 1-4 treatment sessions. It is common for folks to be symptom-free following treatment, especially if there is no sign of other vestibular condition involvement.

Can benign paroxysmal positional vertigo happen more than one time? 

The short answer to this question is yes, BPPV can happen more than one time. When this happens, researchers and medical professionals call this BPPV recurrence. 

Research literature about BPPV recurrence shows:

• Most recurrences happen in the first year after an episode, and there is an approximately 50% recurrence rate within 10 years (11) 
  

• There is a recurrence rate of roughly 15% per year (12)  
  

• Folks with other health conditions, such as hypertension, diabetes, osteoarthritis, osteoporosis, and depression, are more likely to experience BPPV recurrence (13)
  

• Having a history of three or more previous episodes prior to treatment was related to a higher risk of future multiple recurrences(13)
  

Despite all of this information, there is no way to accurately predict if or when another episode may happen. I recommend that folks return to their normal activities and try to focus on how they are feeling between episodes versus worrying about potential future episodes.

Is there anything that I should consider changing if I’ve had BPPV?  

One of the first things most folks with BPPV ask me about is whether there is anything they should be changing to prevent a future episode of BPPV. At this time, research does not support avoiding any activities or positions, so be as active as you can be! 

There is research that points to vitamin D deficiency and high total cholesterol levels, and migraine as risk factors for BPPV. Following up with your family doctor to have bloodwork done to check both your vitamin D and cholesterol levels if they haven’t been worked up recently is an important step in your overall health. For those with poorly managed migraines, starting to work with your healthcare to get them better under control is advised. 

Having other health conditions (see section above) can increase your risk of BPPV recurrence. Making sure you manage these health conditions as well as you’re able to improve your overall health status will most definitely help you feel your best. I’m confident that future research will continue to provide more information about the role of these conditions and how best to manage their impacts.

If you are looking for vestibular therapy in Toronto, I can be found on St Clair Ave West between Lansdowne Ave and Dufferin St. Read more about vestibular physiotherapy, reach out with any questions you have, or book in for an appointment using the button below.

Updated: October 12, 2024

Resources:

1. Parnes, L. S., Agrawal, S. K., & Atlas, J. (2003). Diagnosis and management of benign paroxysmal positional vertigo (BPPV). Canadian Medical Association Journal, 169(7), 681–693.
   

2. Von Brevern, M., Bertholon, P., Brandt, T., Fife, T., Imai, T., Nuti, D., & Newman-Toker, D. (2015). 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, 25(3,4), 105–117. https://doi.org/10.3233/VES-150553
   

3. Von Brevern, M., Radtke, A., Lezius, F., Feldmann, M., Ziese, T., Lempert, T., & Neuhauser, H. (2006). Epidemiology of benign paroxysmal positional vertigo: A population based study. Journal of Neurology, Neurosurgery & Psychiatry, 78(7), 710–715. https://doi.org/10.1136/jnnp.2006.100420
   

4. Van Dam, V. S., Maas, B. D. P. J., Schermer, T. R., Van Benthem, P.-P. G., & Bruintjes, T. D. (2021). Two Symptoms Strongly Suggest Benign Paroxysmal Positional Vertigo in a Dizzy Patient. Frontiers in Neurology, 11, 625776. https://doi.org/10.3389/fneur.2020.625776
   

5. Chen, J., Zhao, W., Yue, X., & Zhang, P. (2020). Risk Factors for the Occurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis. Frontiers in Neurology, 11, 506. https://doi.org/10.3389/fneur.2020.00506
   

6. Wu, Y., Han, K., Han, W., Fan, Z., Zhou, M., Lu, X., Liu, X., Li, L., & Du, L. (2022). Low 25-Hydroxyvitamin D Levels Are Associated With Residual Dizziness After Successful Treatment of Benign Paroxysmal Positional Vertigo. Frontiers in Neurology, 13, 915239. https://doi.org/10.3389/fneur.2022.915239
   

7. Ding, J., Liu, L., Kong, W.-K., Chen, X.-B., & Liu, X. (2019). Serum levels of 25-hydroxy vitamin D correlate with idiopathic benign paroxysmal positional vertigo. Bioscience Reports, 39(4), BSR20190142. https://doi.org/10.1042/BSR20190142
   

8. Sheikhzadeh, M., Lotfi, Y., Mousavi, A., Heidari, B., & Bakhshi, E. (2016). The effect of serum vitamin D normalization in preventing recurrences of benign paroxysmal positional vertigo: A case-control study. Caspian Journal of Internal Medicine, 7(3), 173–177.
   

9. Sheikhzadeh, M., Lotfi, Y., Mousavi, A., Heidari, B., Monadi, M., & Bakhshi, E. (2016). Influence of supplemental vitamin D on intensity of benign paroxysmal positional vertigo: A longitudinal clinical study. Caspian Journal of Internal Medicine, 7(2), 93–98.
   

10. Pollak, L., & Pollak, E. (2014). Headache during a cluster of benign paroxysmal positional vertigo attacks. The Annals of otology, rhinology, and laryngology, 123(12), 875–880. https://doi.org/10.1177/0003489414539921
    

11. Brandt, T., Huppert, D., Hecht, J., Karch, C., & Strupp, M. (2006). Benign paroxysmal positioning vertigo: a long-term follow-up (6-17 years) of 125 patients. Acta oto-laryngologica, 126(2), 160–163. https://doi.org/10.1080/00016480500280140
    

12. Nunez, R. A., Cass, S. P., & Furman, J. M. (2000). Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Otolaryngology--head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery, 122(5), 647–652. https://doi.org/10.1016/S0194-5998(00)70190-2
    

13. De Stefano, A., Dispenza, F., Suarez, H., Perez-Fernandez, N., Manrique-Huarte, R., Ban, J. H., Kim, M. B., Strupp, M., Feil, K., Oliveira, C. A., Sampaio, A. L., Araujo, M. F. S., Bahmad, F., Ganança, M. M., Ganança, F. F., Dorigueto, R., Lee, H., Kulamarva, G., Mathur, N., … Croce, A. (2014). A multicenter observational study on the role of comorbidities in the recurrent episodes of benign paroxysmal positional vertigo. Auris Nasus Larynx, 41(1), 31–36. https://doi.org/10.1016/j.anl.2013.07.007