What is BPPV (Benign Paroxysmal Positional Vertigo)?

Benign paroxysmal positional vertigo or BPPV is a common disorder of the inner ear that produces a sudden episode unsteadiness (spinning or dizziness), nausea and or occasionally ‘brain fog’.  The severity of the BPPV episode can last for seconds or up to a full minute and while BPPV generally affects one ear at a time, it’s possible for both ears to be affected.

BPPV is generally triggered by specific changes or adjustments in your head's position. This can occur with a sudden head motion, when tipping your head up or down, when laying down, or perhaps when turning over or sitting up in bed.  In severe cases, even the slightest head movement could trigger nausea and vomiting and BPPV cases can be worsened by any number of issues which may vary between people such as:

• Barometric pressure changes - patients frequently feel symptoms about 2 days before rain or snow 
• Sleep quality
• Stress

What’s happening with BPPV is tiny calcium crystals (called otoconia), normally located in one part of the vestibular (or balance) system of your inner ear sensory organ (the utricle) and essential for maintaining bodily balance. Otoconia:

1. become dislodged as your head moves
2. travel freely flowing within the fluid-filled spaces of the inner ear 
3. collect in another part of the inner ear balance system, one of the fluid-filled semicircular canals that are sensitive to gravity and changes in head position
4. trigger sensors that relay incorrect messages on balance and movement to your brain and eyes

The brain receives these incorrect messages that the head is moving steadily although the head has only slightly moved position. This often produces symptoms such as an illusion of spinning with common movements or changes in head position when rolling over in bed, getting in or out of bed.  BPPV can disappear within a few days on it’s own - or it can linger with dangerous symptoms, particularly for older adults as the unsteadiness of BPPV can lead to falls, which are a leading cause of fractures in older adults. 

What causes BPPV (Benign Paroxysmal Positional Vertigo)?

When the tiny calcium crystals (otoconia) dislodge and travel within the fluid-filled spaces of the inner ear, they usually flow and collect in the posterior  fluid-filled semicircular canal given its orientation relative to gravity at the lowest part of the inner ear.  This is why the posterior canal is the most affected canal of the ear, but the superior and horizontal canals can be affected as well. 

The otoconia flow and gathering to the posterior fluid-filled semicircular canal in and of itself will not cause a problem until the person’s head adjusts position, such as when going from lying to seated, looking up or down, or when rolling over in bed. That’s when the tiny calcium crystals (otoconia) stimulate sensors in the ear and the “balance (eighth cranial) nerve” launching incorrect messages to the brain and then eyes causing vertigo (spinning dizzy sensation) and or jumping eyes (nystagmus).

Research has concluded anywhere from 50% to 70% of BPPV cases develop without a known cause and are categorized as primary or idiopathic BPPV.   Having said that, the remaining cases are categorized as secondary BPPV and frequently associated with aging (normal wear and tear of the structures of the ear).  So while there is no specific event that triggers BPPV,  BPPV commonly accompanies:

• migraines
• head trauma from a fall, accident or sports injury
• keeping the head in the same position for extended periods of time, such as at the beauty salon, in the dentist chair, or over the course of a long flight on an airline
• bike riding on rough trails
• high intensity aerobics
• inner ear disease (inflammation, labyrinthitis, vestibular neuritis, acoustic neuroma).

BPPV does haver risk factors which include:

• Female gender
• Hypertension (HTN)
• Hyperlipidemia
• Cerebrovascular disease
• Menopause
• Allergies
• Migraine
• Chronic Obstructive Pulmonary Disease 
• Surgical procedure such as a cochlear implant
• Infection

Why changes in head position cause BPPV, a closer look 

BPPV happens when tiny dislodged calcium crystals (otoconia) flow into your inner ear structures that control balance, one being the posterior fluid-filled semicircular canal - and become trapped. Normally, the otoconia are securely positioned in part of your inner ear’s sensory organ, the utricle - however the otoconia can become dislodged due to infection, injury, or age.  Once dislodged, simple changes in head position can send the loose otoconia traveling throughout the inner ear, with some otoconia inevitably flowing into the ear’s posterior fluid-filled semicircular canal and stimulating its sensory receptors ciliate hairs structures.  This stimulation in one ear is unbalanced with respect to the opposite ear resulting and incorrect signals about balance being transmitted (via the eighth cranial nerve)  to the brain.  In sum, the displacement of the otoconia into the fluid-filled semicircular canals, amounts to a delicate feedback loop relaying conflicting balance signals that can result in any of numerous symptom related to BPPV.

Diagnosing BPPV (Benign Paroxysmal Positional Vertigo)  in Atlanta, GA

Testing for BPPV is simple and should be considered by anyone experiencing recently developed vertigo symptoms such as:

• loss of balance during everyday tasks
• dizziness after moving your head, sitting up quickly, or lying down
• nausea and vomiting

Diagnosing BPPV starts with taking a subjective assessment as complaints of dizziness require taking of a detailed patient history including previous injuries or medical procedures along with an exploration of the current symptoms.    This is generally followed with a test called the Dix-Hallpike Maneuver, the ‘gold standard’ used to trigger, diagnose, and determine treatment for BPPV.  The Dix-Hallpike maneuver calls for the patient to be quickly moved from a sitting posture to the supine posture (lying on your back with the face pointing upward) and head turned 45 degrees to the direction of the affected ear. After brief moment the patient is returned to the sitting position and observations are made by the therapist.   

Dix-Hallpike Maneuver steps are as follows:

• You’ll be asked to sit upright on an exam table, legs stretched out front and your head turned about 45-degrees to one side.
• You’ll be asked to lower your head along with your torso back so that you’re ultimately lying with your head stretched beyond the edge of the exam table, turned with one ear down at a 45-degree angle. 
• If there are any dislodged tiny calcium crystals that have traveled to the posterior canal of your inner ear, they will be triggered and  vertigo symptoms (dizziness & spinning) will be experienced. 
• In this position you’ll be checked for involuntary, rapid and sometimes repetitive movement of the eyes called nystagmus,  indicating dizziness.  You’re usually asked to describe how you’re feeling prior to switching sides and testing the opposite ear.

We can usually give you the results and observations right away - which would dictate next steps in a treatment plan if needed.  If vertigo is triggered by the Dix-Hallpike maneuver, it’s likely your posterior ear fluid-filled semicircular canal on the right, left, or both sides is affected by BPPV.  If your Dix-Hallpike test is negative, it’s likely other issues are causing your vertigo symptoms, such as:

• migraine
• ear infection
• inflammation of the nerves inside your ear (called vestibular neuritis)

False negatives do happen, so it does not conclusively mean that BPPV isn’t what’s causing your vertigo. In some cases, we may need to repeat the maneuver again before being tested for other conditions. 

Treating BPPV (Benign Paroxysmal Positional Vertigo) in Atlanta, GA

The most effective BPPV treatments involve physical therapy exercises. The objective BPPV exercises is to move the tiny calcium crystals out of semicircular canals and back to the utricle where they resorb more readily and don’t cause disorienting symptoms. In most cases BPPV can be treated effectively and successfully — without pills, surgery, special equipment or any further elaborate tests — by using what is known as the Epley maneuver, an exercise that generally requires about 15 minutes to perform and complete.

Left Ear Epley Maneuver

Right Ear Epley Maneuver

Both simple and effective, the Epley maneuver involves slowly sequentially turning the head and neck in such a way that helps the tiny calcium crystals (otoconia)  flow out and away from the posterior fluid-filled semicircular canal.   

We guide you through this exercise here at our clinic and after performing the Epley maneuver, patients can carefully return to walking but should avoid putting the head back as if looking straight up toward the sky or bending their head far forward as if to tie their shoes - for the remainder of the day. Sleeping on the side of the ear affected should be avoided for a few days.  

If the tiny calcium crystals are located in places other than the posterior semicircular canal, slightly different maneuvers can be applied, but based on the same goal of migrating the tiny loose calcium crystals out of the fluid-filled semicircular canals they occupy.  

Usually medications are not required for treating BPPV unless the patient has severe vomiting or nausea. In cases of extreme nausea anti-nausea medications could be an option.  

2 BPPV (Benign Paroxysmal Positional Vertigo) Exercises For Home  

Exercise 1: Here are the step-by-step instructions of a basic BPPV Vertigo exercise regime that you can try at home:

• Step 1: Begin by sitting on a bed in such a way that not now but in upcoming steps - there is room for you to extend your head over the edge of the bed when you lie back.   So while sitting upright on a bed toward the affected ear, turn your head about 45 degrees.
• Step 2: Now swiftly lie back to where your head is extended over the edge of the bed, keeping your head in that 45 degree turned position toward the affected ear - and rest right there.  You’ll likely experience spinning or dizziness as you do, wait about a minute or until you stop having symptoms in this position.
• Step 3: With your slightly extended over the edge of the bed head at that 45 degree angle and without raising it,  quickly turn your head in the opposite direction and toward your  “good” ear to where you affected ear is facing upward toward the ceiling.  You’ll likely experience spinning or dizziness as you do, wait about a minute or until you stop having symptoms in this position.
• Step 4: Roll the rest of your body onto your side so it’s now aligned with your affected ear, and while keeping your body sideways, continue to turn your head another 90 degrees (or as much as you can) in the direction as you did in step 3 so that your nose is now facing at downward angle, toward the floor as much as possible. Your chin should be very close to your shoulder.   Wait in that position for about a minute.  
• Step 5: For the final step, keep your chin tucked in toward your shoulder as you sit up in the direction your body’s facing.  This routine should be effective in what’s called, “particle repositioning” or moving the tiny calcium crystals out of semicircular canals and back to the utricle where they resorb more readily and don’t cause disorienting symptoms.

Exercise 2: Another more simple protocol you can try at home is called the Brandt-Daroff exercises which can help move the calcium crystals that are causing the BBPV.  To perform Brandt-Daroff exercises:

1. Sit at the edge of your bed and near, llegs hanging over the side.
2. Lie down to the right side with your body and turn your head up toward the ceiling. Stay in this position for 30 seconds and if you sense spinning or feel dizzy, hold this position until it passes.
3. Return to the original upright position and stare directly straight ahead for 30 seconds.
4. Repeat the 2nd step using the left side of your body for 30 seconds.
5. Again, return to sitting upright and stare straight ahead for 30 seconds.
6. Do additional sets at least 3 to 4 times per day.

In many instances, BPPV eventually goes away on its own entirely - however can return.  While BPPV can’t be prevented, it can be manage it with particle repositioning exercises.  At FYZICAL Therapy & Balance Centers - Alpharetta, our team of experienced therapists is dedicated to helping our patients diagnose and alleviate the causes of BPPV to achieve optimal health and wellness.