Benign Paroxysmal Positional Vertigo

Aka: Benign Paroxysmal Positional Vertigo, Paroxysmal Positional Vertigo, BPPV

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II. Epidemiology

  1. Most common in ages 50 to 70 years old

III. Causes

  1. Idiopathic in >50% of older patients
  2. Ear Trauma may precipitate (esp. younger patients with BPPV)

IV. Pathophysiology

  1. Temporary displacement of otolith (otoconia, canaliths)
    1. Displaced onto gelatinous capsule
    2. Typically canaliths dislodged from vestibule into the posterior semicircular canal
  2. Symptoms persist until otolith (loose bodies) resorbed or repositioned into vestibule

V. Symptoms

  1. Severity
    1. Severe episodic Vertigo
  2. Provocative
    1. Only change of head position triggers Vertigo
    2. Provoked by turning onto one side (not the other)
    3. Vertigo with vertical head movements
      1. Provoked by extending neck while looking up
    4. Recurs with similar movement
      1. However, exhibits fatigability (effect diminishes with consecutive provocative maneuvers)
    5. Asymptomatic at rest
  3. Palliative
    1. Visual Fixation
  4. Duration
    1. Environment spins for 10-20 seconds (max of 60 seconds), then resolves
  5. Timing
    1. Symptom onset is delayed for seconds after the precipitating head movement (latency)
    2. Occurs at night while recumbent

VI. Signs

  1. Dix-Hallpike Maneuver elicits symptoms
  2. Rotary Nystagmus accompanies vertigo Sensation

VII. Precautions: Neurologic Red Flags suggestive of alternative diagnosis

  1. Dysarthria
  2. Diplopia
  3. Dysmetria
  4. Dysphagia
  5. Dysdiadochokinesia (DDK)
    1. Inability to perform rapid, alternating movements

VIII. Differential Diagnosis

  1. See Vertigo Causes
  2. Diagnosis of exclusion
    1. Rule out CNS and Ear organic disease
      1. BPPV is a Triggered Vestibular Syndrome and should not persist without provocation
      2. Acute Vestibular Syndrome (constant Vertigo), especially with positive HiNTs Exam is CVA until proven otherwise
    2. No Neurologic Red Flags (see above)
    3. Vertigo is classic for BPPV (see symptoms and signs above)
      1. Head movement consistently produces severe, brief Vertigo with rotary Nystagmus
        1. Dix-Hallpike Maneuver positive
        2. Contrast with Vestibular Neuritis which persists regardless of provocation
      2. Vertigo lasts <60 seconds, and exhibits latency and fatigability
      3. Visual Fixation and avoiding head movement are palliative

IX. Management

  1. See Vertigo Management
    1. Primary management is with Canalith Repositioning, not medications
    2. Exercise caution with medications due to risk of falls, and circumventing central compensation
  2. Canalith Repositioning Procedure (Epley Maneuver)
    1. As effective as medication therapy and recommended as part of acute medical care (including ED care)
    2. Successful in 70% of first trials (approaches 100% on further attempts)
    3. Hilton (2014) Cochrane Database Syst Rev (12):CD003162 [PubMed]
    4. Sacco (2014) J Emerg Med 46(4): 575-81 [PubMed]
  3. Brandt-Daroff Exercises
    1. Repositioning maneuvers performed by patient at home
      1. Mechanism may be to habituate to Vertigo rather than return canaliths to vestibule (Epley is preferred)
    2. https://www.youtube.com/watch?v=CTZfIv165sY
    3. http://www.ncuh.nhs.uk/our-services/brandt-daroff-excercises-quick-guide.pdf

X. Course

  1. Self limited
  2. Symptoms resolve in 4-6 weeks
  3. Prolonged disabling symptoms in 33% of patients

XI. References

  1. Arora and Menchine in Herbert (2014) EM:Rap 14(6): 2
  2. Baloh (1987) Neurology 37:371-8 [PubMed]
  3. Baloh (1999) Postgrad Med 105(2):161-72 [PubMed]
  4. Muncie (2017) Am Fam Physician 95(3): 154-62 [PubMed]

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