Benign paroxysmal positional vertigo (BPPV): symptoms, tests and treatment

The name describes the condition. Benign means the cause is neither cancerous nor serious, paroxysmal means episodes that come and go often without warning, positional means certain head positions set it off, and vertigo is the false sense that you or the world is moving. Patient.info describes feeling very unsteady, a bit like being on a ship, and often feeling sick without actually vomiting.

It is a mechanical problem rather than an infection. Tiny calcium carbonate crystals called otoconia, thought to have broken away from the lining of the vestibule, drift into one of the fluid-filled semicircular canals of the inner ear. When the head moves, they shift with the fluid and brush against the sensory hairs, sending a burst of signals that conflicts with the normal input from the other ear and the eyes. The brain reacts with vertigo. It is not clear why the crystals detach.

The defining feature is brevity. Patient.info says the spinning typically lasts 20 to 30 seconds and usually no longer than a minute, and disappears if the head is kept still. Nausea may outlast the vertigo by an hour or so. Between episodes you feel well. Many people learn which movements provoke an attack, such as turning over in bed or tilting the head back, and instinctively avoid them.

The NHS general vertigo advice describes an attack as lasting from a few seconds to hours, and in severe cases days or months, which highlights why a diagnosis matters: BPPV is brief and positional, whereas long continuous spinning suggests other causes.

Age-related BPPV is one of the most common causes of vertigo in older people, and most cases occur after 40. Some younger people develop it after a blow to the head or following an inner-ear infection, and sometimes there is no apparent reason. The NHS lists BPPV among inner-ear causes of vertigo, along with labyrinthitis, vestibular neuritis and Ménière's disease, and also names migraine and some medicines as other causes.

The pattern of symptoms is often enough for a doctor to suspect BPPV. The NHS says a GP may ask you to move quickly from sitting to lying down to see whether this brings on symptoms. Patient.info names this as the Dix-Hallpike manoeuvre: you sit on a couch, then lie back with the head turned in set directions, which usually triggers an episode in BPPV and lets the clinician see the characteristic eye movements.

You should seek advice if vertigo is persistent rather than coming and going, if hearing loss or tinnitus develops alongside it, or if the attacks are frequent or troubling enough to affect your life, according to Patient.info. If the picture is unclear, or if diagnosed BPPV does not settle, referral to an ENT specialist is usual because the lateral or anterior canals, which are harder to treat, may be involved.

BPPV often clears by itself over weeks or months, as the crystals dissolve or settle somewhere harmless. When treatment is wanted, the Epley manoeuvre is the usual choice for the common posterior canal type. It involves four head movements, each held for about 30 seconds, using gravity to move the crystals out of the canal. Patient.info says studies report it stops symptoms in about 8 in 10 people with a single treatment, and that a repeat session a week or so later often works if the first does not. It can be repeated if symptoms return.

The Semont manoeuvre is an alternative that moves you quickly from lying on one side to the other and may suit people with neck stiffness. Brandt-Daroff exercises can be done at home and may provoke dizziness in the short term but often lead to longer-term relief. Surgery is extremely rare and considered only when symptoms persist for months or years and cannot be eased.

The NHS says antihistamines can sometimes help vertigo symptoms in general, and that treatment depends on the cause. Medicines are not the main treatment for BPPV itself, because the problem is mechanical. Sleep with your head slightly raised on two or more pillows, sit on the edge of the bed before standing, and avoid bending to pick things up or stretching your neck, as the NHS vertigo advice suggests.

The NHS says anyone with vertigo who drives must tell the DVLA, and Patient.info quotes DVLA guidance to stop driving if you have sudden, unexpected and disabling attacks of dizziness. Tell your employer if the condition could create risk at work, for example when using ladders or machinery.

Vertigo is usually not an emergency, but the NHS lists symptoms that change that. Call 999 or go to A&E if vertigo comes with double vision or loss of vision, hearing loss, trouble speaking, or weakness, numbness or tingling in the legs or arms. Ask for an urgent GP appointment or NHS 111 if you have vertigo together with a severe headache, are being sick, or have a very high temperature or feel hot, cold or shivery. These are not typical of BPPV and need prompt assessment.

Most people are diagnosed in primary care, and some GPs or physiotherapists perform repositioning manoeuvres. Persistent or atypical cases are referred to ENT, audiology or a balance clinic. Vestibular physiotherapists can treat recurrent cases and teach home exercises.

Private ENT or audiovestibular clinics can offer faster specialist assessment and in-clinic repositioning. If you pursue that, ask which canal was found to be affected, which manoeuvre was used and what to do if symptoms return.