Key Points
- A primary complaint of dizziness accounts for 5.6 million clinic visits in the United States per year.
- Between 17% and 42% of patients with vertigo ultimately receive a diagnosis of benign paroxysmal positional vertigo (BPPV).
- BPPV can recover spontaneously in approximately 20% of patients by one month of follow-up and up to 50% at three months.
- Patients with BPPV are at increased risk for falls and impairment in the performance of daily activities and adverse effects on individual health-related quality of life and utility measures.
- BPPV is most commonly clinically encountered as one of two variants:
- Posterior canal BPPV is more common than horizontal canal BPPV, constituting approximately 85–95% of BPPV cases.
- Lateral (horizontal) canal BPPV accounts for between 5% and 15% of BPPV cases.
Table 1. Definitions of Words Used in the Guideline
Vertigo | An illusory sensation of motion of either the self or the surroundings in the absence of true motion. |
Nystagmus | A rapid, involuntary, oscillatory movement of the eyeball. |
Vestibular system/apparatus | The sensory system within the inner ear that together with the vestibular nerve and its connections in the brain provides the fundamental input to the brain regarding balance and spatial orientation. |
Positional vertigo | Vertigo produced by changes in the head position relative to gravity |
Benign paroxysmal positional vertigo (BPPV) | A disorder of the inner ear characterized by repeated episodes of positional vertigo. |
Posterior canal BPPV | A form of BPPV in which dislodged inner ear particles in the posterior semicircular canal abnormally influence the balance system producing the vertigo, most commonly diagnosed with the Dix-Hallpike test. |
Lateral canal BPPV | A form of BPPV in which dislodged inner ear particles in the lateral semicircular canal abnormally influence the balance system producing the vertigo, most commonly diagnosed by the supine roll test. |
Canalithiasis | A theory for the pathogenesis of BPPV that proposes that there are free-floating particles (otoconia) that have moved from the utricle and collect near the cupula of the affected canal, causing forces in the canal leading to abnormal stimulation of the vestibular apparatus. |
Cupulolithiasis | A theory for the pathogenesis of BPPV that proposes that otoconial debris attached to the cupula of the affected semicircular canal cause abnormal stimulation of the vestibular apparatus. |
Canalith repositioning procedures (CRP) | A group of procedures in which the patient moves through specific body positions designed to relocate dislodged particles within the inner ear for the purpose of relieving symptoms of BPPV. The specific CRP chosen relates to the type of BPPV diagnosed. These have also been termed canalith repositioning maneuvers or canalith repositioning techniques. |
Table 2. Summary of Key Action Statements (KAS)
| Statement | Action | Grade |
|---|---|---|
1a. Diagnosis of posterior canal BPPV | Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, up-beating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45º to one side and neck extended 20º with the affected ear down. The maneuver should be repeated with the opposite ear down if the initial maneuver is negative. | S-B |
1b. Diagnosis of lateral (horizontal) canal BPPV | If the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus, the clinician should perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV. | R-B |
2a. Differential diagnosis | Clinicians should differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo. | R-C |
2b. Modifying factors | Clinicians should assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling. | R-C |
3a. Radiographic testing | Clinicians should NOT obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging. | R-C (against) |
3b. Vestibular testing | Clinicians should NOT order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing. | R-C (against) |
4a. Repositioning procedures as initial therapy | Clinicians should treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. | S-A |
4b. Postprocedural restrictions | Clinicians should NOT recommend postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. | S-A (against) |
4c. Observation as initial therapy | Clinicians may offer observation with follow-up as initial management for patients with BPPV. | O-B |
5. Vestibular rehabilitation therapy | The clinician may offer vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV. | O-B |
6. Medical therapy | Clinicians should NOT routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. | R-C (against) |
7a. Outcome Assessment | Clinicians should reassess patients within one month after an initial period of observation or treatment to document resolution or persistence | R-C |
7b. Evaluation of treatment failure | Clinicians should evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders. | R-A |
8. Education | Clinicians should educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence and the importance of follow-up. | R-C |
Management
Table 3. Basic Differential Diagnosis of BPPV
| Otologic disorders | Neurologic disorders | Other entities |
|---|---|---|
Meniere’s disease Vestibular neuritis Labyrinthitis Superior canal dehiscence syndrome Posttraumatic vertigo Perilymphatic fistula Inner ear lesions | Vestibular migraine Posterior circulation TIA and stroke Demyelinating diseases Central nervous system lesions Vertebrobasilar insufficiency Central positional vertigo | Anxiety or panic disorder Cervicogenic vertigo Medication side effects Postural hypotension Various medical conditions (such as toxic, infectious and metabolic conditions) |
Table 4. Common Causes of Acute Dizziness: Differential Diagnosis by Timing and Triggers Category
| Acute vestibular syndrome | Triggered episodic vestibular syndrome | Spontaneous episodic vestibular syndrome | Chronic vestibular syndrome |
|---|---|---|---|
Vestibular neuritis Labyrinthitis Posterior circulation stroke Demyelinating diseases Post-traumatic vertigo | BPPV Postural hypotension Perilymph fistula Superior canal dehiscence syndrome Vertebrobasilar insufficiency Central paroxysmal positional vertigo | Vestibular migraine Meniere’s disease Posterior circulation TIA Medication side effects Anxiety or panic disorder | Anxiety or panic disorder Medication side effects Posttraumatic vertigo Posterior fossa mass lesions Cervicogenic vertigo (variable) |
Table 5. Diagnostic Criteria for Posterior Canal BPPV
History | Patient reports repeated episodes of vertigo with changes in head position relative to gravity |
Physical Examination | Each of the following criteria is fulfilled:
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Table 6. Selected Methods to Determine the Affected Ear in Lateral Canal BPPV
| Technique or Circumstance | Conclusion regarding the affected ear |
|---|---|
Supine roll testing (Figure 2) reveals a direction changing nystagmus that is either geotropic (beating toward the ground) or apogeotropic (beating away from the ground) and is distinctly stronger on one side than the other. |
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Posterior canal BPPV torsional upbeating nystagmus converts to strongly horizontal nystagmus (lateral canal BPPV) during positioning. |
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Patient is moved from sitting to straight supine facing up results in transient horizontal nystagmus (lying-down nystagmusa). |
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With the patient in the straight supine position, the patient then sits up, and the head bends down as a “Head Pitch Test” (head-bending nystagmus). |
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Bow and lean test (BLT)a in which the direction of nystagmus is noted when the patient bends the head forward facing down (bowing) and when facing upward (leaning). |
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a The supine head roll test will still be needed to determine if there is a pattern of geotropic or apogeotropic direction-changing nystagmus.
