Benign Positional Dizziness

Benign paroxysmal positional vertigo (BPPV) is brief rotational vertigo triggered by head position change, caused by displaced otoconia in a semicircular canal. The posterior canal is involved in about 85 to 90 percent, the lateral canal in most of the rest.

• Peaks in the sixth decade, female predominance.
• Causes: idiopathic, head trauma, vestibular neuritis, prolonged bed rest, migraine, osteoporosis.
• Recurrence in 15 to 50 percent within 5 years.

Episodes of spinning vertigo lasting under 1 minute on rolling in bed, looking up, bending or lying back.

• Nausea common; no hearing loss, tinnitus or neurological signs.
• Dix Hallpike: torsional upbeating nystagmus with latency of 1 to 5 seconds, lasting under 1 minute, fatigable and reversing on sitting up.
• Lateral canal: supine roll test shows horizontal geotropic (stronger toward the undermost ear) or apogeotropic nystagmus.
• Differential diagnosis: vestibular migraine, central positional vertigo (cerebellar tumour, stroke, multiple sclerosis), orthostatic hypotension, Meniere disease, vestibular neuritis, perilymph fistula, cervical vertigo, anxiety.
• Complications: falls and fractures, anxiety, avoidance behaviour, motion sickness, canal conversion, recurrence.

Clinical, confirmed by positional testing.

• Dix Hallpike for posterior canal; supine roll test for lateral canal.
• Blood pressure lying and standing, glucose, otoscopy.
• Imaging only for central features: non fatigable nystagmus, pure vertical downbeat nystagmus, severe ataxia, persistent symptoms without positional change, or failure of repositioning.

Canalith repositioning is curative and drugs have no role in treating the condition.

• Supportive: explain the benign course, fall precautions, advise slow position changes, sleep with head slightly raised.
• Pharmacological: none for cure; prochlorperazine 5 mg orally once or twice for severe nausea around the manoeuvre, for no longer than 3 days.
• Procedures: Epley manoeuvre for posterior canal. Sit with head turned 45 degrees toward the affected ear; lie back quickly with head hanging 20 degrees below the horizontal and hold 30 to 60 seconds until nystagmus ends; turn head 90 degrees toward the opposite side and hold 30 to 60 seconds; roll the body and head another 90 degrees until facing down at 45 degrees and hold 30 to 60 seconds; sit up. Repeat once if symptoms persist. Semont manoeuvre as an alternative. Lateral canal: barbecue roll (rotate in 90 degree steps with 30 to 60 seconds in each) or Gufoni manoeuvre. Home exercises (Brandt Daroff) if clinic manoeuvres fail, repeated three times daily.
• Special groups: pregnancy, manoeuvres are safe; elderly with neck or spine disease or cardiovascular fragility, use a modified manoeuvre or Semont; avoid long term vestibular suppressants.
• Red flags: non fatigable or direction changing nystagmus, vertical nystagmus, severe headache, new neurological signs, no response after 2 to 3 repositioning attempts.
• Follow-up: recheck in 1 to 2 weeks; repeat manoeuvre if positive; teach home self treatment for recurrence; check vitamin D and bone health in recurrent cases.