What is Benign Paroxysmal Positional Vertigo?
Benign Paroxysmal Positional Vertigo (BPPV)
Benign paroxysmal positional vertigo, or BPPV, is one of the most common causes of dizziness and vertigo. It can cause a sudden feeling that you’re spinning or falling, or that the room is spinning around you. It can make it hard to stand or keep your balance, make walking difficult, and bring on nausea and vomiting. BPPV can range from a mild annoyance to a severely disabling problem, and it can be a source of real anxiety and frustration.
Some serious conditions, including stroke, can look like BPPV. Call 911 for sudden dizziness with weakness, numbness, trouble speaking, double vision, a severe headache or trouble walking.
How Common Is BPPV?
BPPV is the most common cause of vertigo. It accounts for roughly 30% of diagnoses in people seen for dizziness (1).
BPPV becomes more common with age and is a leading cause of dizziness and falls in older adults (2).
What Are the Symptoms of BPPV?
The most common symptom of BPPV is a brief spinning or falling sensation after tilting or turning your head. BPPV can also cause clumsiness, trouble with balance and walking, and problems with quick movements. Some people feel lightheaded and disoriented, as if they might pass out, and nausea and vomiting are common.
BPPV can make it hard to get out of bed without losing your balance or falling. It can also cause trouble thinking and brain fog. For some people, anxiety and panic become one of the most noticeable symptoms.
What Causes BPPV?
Your inner ear’s balance system, the vestibular system, has two kinds of sensors: the otoliths and the semicircular canals.
The otoliths sit in a fluid-filled chamber called the vestibule. They sense your head’s position relative to gravity, such as when it tilts, and straight-line movement, like moving up and down or side to side. The otolith hair cells are covered by a gel layer topped with tiny calcium crystals, called otoconia. The weight of these crystals pulls the hair cells toward gravity. When the hair cells bend, they send signals through the vestibular nerve to the brainstem, cerebellum and brain. No matter how your head is positioned, some hair cells are always being pulled toward gravity, which tells your brain where your head is at all times.
The inner ear also contains three fluid-filled semicircular canals on each side, which sense head rotation. When your head turns, the fluid lags behind for a moment because of inertia. This bends the hair cells in the canal, which send signals to the brainstem, cerebellum and brain about which direction your head is turning.
The fluid in the vestibule connects to the semicircular canals. For many reasons, otoconia crystals can sometimes break loose and drift through the vestibule, and some can float into one or more of the semicircular canals, where they don’t belong.
BPPV happens when these loose crystals get into a semicircular canal. Normally, the canals respond only to head rotation, not gravity. But with crystals inside, the canal becomes sensitive to gravity. When you change head position, the crystals sink toward the bottom of the canal, dragging the fluid with them. This bends the hair cells and creates a false sensation of movement.
How Does BPPV Affect Your Life?
In many cases, BPPV is mild and goes away on its own. It often starts after time tilted back in a dentist’s chair or with your head tipped back at a hair salon sink. Many people wake up feeling fine, roll onto their side, and a few seconds later the room starts spinning as crystals drift down a canal.
BPPV can also become long-lasting and even disabling, especially when more than one canal is involved.
When BPPV lasts a long time, the brain starts to compensate for the faulty signals from the affected canal. Vertigo comes from a sensory mismatch: the signal from the affected canal doesn’t match what your eyes and body are telling your brain. Over time, the brain may learn to tune out the faulty signal and accept it as a new normal. But that doesn’t mean all symptoms go away. Some people with long-standing BPPV mainly notice anxiety and panic, trouble thinking, headaches, memory problems and other neurological symptoms.
Sometimes symptoms fade not because the crystals have cleared, but because the brain has adapted around the problem. Our brains are always adapting to their environment, a process called neuroplasticity. When the signals coming from the inner ear change, the brain tries to adjust. You may stop feeling dizzy, but you may develop other symptoms, such as neck or back pain, headaches, brain fog, trouble with planning and focus, balance problems or a general feeling of being “off.”
These unresolved sensory mismatches can significantly lower quality of life, especially as we age (3).
How Else Can You Get BPPV?
BPPV is common after a traumatic brain injury or whiplash. Hitting your head on the headrest in a car crash can knock loose a cloud of crystals in the inner ear. People may feel fine after the accident, go to bed and wake up spinning after the crystals settle into a canal. The affected canal then sends the wrong information about where your head is, creating vertigo with certain head movements. Common triggers include lying down, sitting up from lying down, rolling over in bed, looking up, tipping your head back and bending over, such as to tie your shoes.
Dizziness, vertigo and balance problems after a mild traumatic brain injury are estimated to affect anywhere from 15% to 78% of people. BPPV is a common source of dizziness after concussion and often involves more than one canal. BPPV after a head injury is more likely to come back and can be harder to treat than BPPV that starts on its own (3).
How Is BPPV Usually Treated?
BPPV is usually treated with repositioning maneuvers, which move the head through a series of positions that guide the crystals out of the canal and back to where they belong. The most common form of BPPV involves crystals in the posterior canal.
BPPV was once considered incurable and was sometimes treated by surgically cutting the balance nerve. That changed when Portland neurotologist Dr. John Epley developed the Epley maneuver for posterior canal BPPV. It holds the head in a series of sustained positions that let the crystals float back where they belong. This revolutionary maneuver has helped millions of people with vertigo (4).
Dr. Epley was a close friend of our practice, and our Dr. Zielinski had the honor of performing the last repositioning maneuver Dr. Epley observed before his passing.
Simple cases of BPPV may need only one Epley maneuver, while more complicated cases may need several. When the lateral or superior (anterior) canals are involved, other maneuvers are needed. Some cases involve more than one canal, which is common after a head injury.
How the NeuroRescue Program Can Help
Our care is designed to work alongside your physician and other providers, never in place of them.
There are many forms of BPPV, and complicated cases may involve more than one canal. How BPPV started also matters, since BPPV after a head injury is often more complicated to treat and more likely to come back (5). Single posterior canal BPPV is often recognized and treated well in primary care. More complicated forms can be harder to diagnose, and some people with BPPV involving several canals are misdiagnosed, sometimes with anxiety disorders.
Complicated BPPV can be hard to diagnose and treat without the right technology. Identifying which canal is involved requires watching for specific patterns of involuntary eye movements, called nystagmus, that appear when the head is placed in positions that stimulate each canal. These eye movements are best seen when vision is blocked, because looking at a target lets the brain suppress them. Infrared video recording of the eyes, called videonystagmography (VNG), allows this analysis to be done precisely (6).
In more complicated cases, additional testing can help pinpoint which canals are involved. Research has shown that the video head impulse test (vHIT) can help identify affected canals in BPPV when other methods are unclear (7).
As part of your NeuroRescue Program, we use both VNG and vHIT to evaluate complicated forms of BPPV, and we have extensive experience with repositioning maneuvers for every canal.
It’s also important to understand the difference between peripheral and central vestibular disorders. Peripheral vertigo comes from the inner ear itself, and BPPV is the most common type. Central vestibular disorders involve the balance pathways in the brainstem and brain, and they can look like peripheral vertigo (8). Eye movement patterns that don’t fit BPPV can be a sign of a central problem, and if we see them, we’ll make sure you get the right medical evaluation.
Over time, BPPV that isn’t fully resolved can lead the brain to adapt in unhelpful ways as it tries to recalibrate your eye movements around the faulty canal signal. These adaptations are, in effect, a central vestibular problem, and they can create as many problems as they solve. Central vestibular problems require careful testing to identify, and rehabilitation is different for each person. Central vestibular dysfunction is part of many neurological conditions, and it’s something we work with every day.
Depending on your needs and test results, your program may include canalith repositioning maneuvers for BPPV (9); exercises to retrain how your eyes and inner ear work together during head movement (10); eye exercises to improve visual stability (11); non-invasive electrical stimulation of the vestibular system through the skin (12); visual stimulation exercises (13), including visual stimulation combined with head movements (14); and exercises in a virtual reality environment (15). Transcranial magnetic stimulation (TMS) has also been studied for chronic dizziness (16). At our clinic, TMS is provided by our psychiatric mental health nurse practitioner, who will evaluate whether it may be appropriate for you.
No two cases of BPPV are alike, and the same is true for your NeuroRescue Program. The therapies we recommend are always chosen based on your testing and exam findings.
How the NeuroRescue Program Works
Your NeuroRescue Program begins with your Discovery Day. We start with a detailed history of your condition and your life on a timeline. This helps us understand the factors that may have contributed to where you are now, and identify related conditions that may be making it harder to move forward.
We measure how your visual, vestibular and balance systems are working through computerized analysis of your eye movements, inner ear reflexes and balance under different conditions. Our testing includes videonystagmography and saccadometry to measure several types of eye movements, the video head impulse test to measure how each semicircular canal is working, and CAPS computerized posturography to assess your balance under different sensory conditions. We also use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and your perception of vertical in a virtual reality environment.
We combine this with a thorough physical and neurological exam of your sensory, motor, autonomic and cognitive systems. We also review any relevant lab work, imaging and prior testing, and integrate it with our findings.
Together, this helps us understand which parts of your nervous system are working well, which are struggling, and how quickly they tire. We use that information to design your personal NeuroRescue Program, aimed at addressing both the BPPV itself and any lingering effects on your brain and balance. Our testing also helps us decide when to push and when to let you rest.
Our goal is to help you get out of bed, look up, roll over and move through your day without bracing for the room to spin.
Your Next Step
Living with BPPV can be frightening and frustrating, especially when it keeps coming back. You don’t have to keep living with it. To find out if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
It’s never too late to take the next step.
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