Definition and Prevalence
Our sense of balance arises from the brain combining information coming from the balance organ in the inner ear, the eyes, and the sensory receptors in muscles and joints. A disturbance at any point in this system can cause dizziness. One of the most common causes of dizziness is benign paroxysmal positional vertigo (BPPV), popularly known as “displaced crystals”. Microscopic calcium crystals (otoconia) inside the balance organ of the inner ear can, for various reasons, become dislodged and stray into the balance canals; when the head is moved into certain positions, the movement of these crystals inside the canal produces a brief but intense spinning sensation.
Although BPPV can occur in all age groups, it is reported more often in older people and in women. It is one of the most frequent diagnoses made in outpatient clinics among patients who present with dizziness, and when it is correctly diagnosed it can be treated very effectively.
Symptoms
The characteristic feature of BPPV is attacks of spinning dizziness that usually last less than a minute but feel very intense. These attacks are typically triggered by specific head movements such as turning over in bed, getting out of bed or lying down, or tilting the head up or down. Nausea may accompany an attack, and vomiting occurs rarely. Between attacks patients usually feel normal, although in some people a mild sense of unsteadiness may persist for days.
Hearing loss or ringing in the ear is not expected in BPPV. If these findings are present, if the spinning lasts for hours, or if there is severe headache, double vision, speech disturbance, or numbness or weakness in the face or the arms and legs, this suggests that the dizziness may be due to another cause (such as other inner-ear diseases or causes originating in the central nervous system), and in that case an evaluation should be carried out without delay.
Causes and Risk Factors
In most cases of BPPV no definite underlying cause is found (idiopathic BPPV); the natural weakening of the crystal structures in the inner ear with age, and their increasing tendency to become dislodged, account for most of these cases. Head trauma, prolonged bed rest, ear infections, other diseases affecting the inner ear (for example Ménière’s disease) and a history of migraine are among the known risk factors for developing BPPV. Everyday activities such as keeping the head tilted back for a long time in the dentist’s chair, or tipping the head back while having one’s hair washed at the hairdresser, have also been reported as triggers in some patients.
BPPV may occur as a single attack, but it can also recur over time, particularly if the underlying risk factors persist. In some patients, previous inner-ear disorders increase the risk of recurrence.
The Diagnostic Process
The diagnosis is made largely by listening carefully to the patient’s complaints and by positional tests performed during the examination. The most commonly used test is the Dix-Hallpike maneuver: the patient is moved quickly from a sitting position to lying on their back, with the head turned to the side at a specific angle. The characteristic involuntary eye movements (nystagmus) that appear during the test, together with the spinning sensation the patient feels, help identify the affected canal. If involvement of the lateral canal is suspected, additional positional tests such as the supine roll test may be performed.
If hearing-related complaints, neurological findings or an atypical nystagmus pattern are found during the examination, hearing tests, advanced vestibular tests or imaging may be considered for the differential diagnosis. When the history is typical and typical findings are seen on positional testing, the diagnosis can usually be made without the need for further investigations.
Treatment Options
Repositioning Maneuvers
The primary and most effective treatment for BPPV is repositioning maneuvers, which move the crystals out of the affected canal and back into the area of the inner ear where they normally function. The best known of these is the Epley maneuver: the patient’s head and body are moved in a specific sequence and at specific angles so that the crystals travel along the canal and leave it. Depending on the affected canal, the Semont maneuver or, in lateral-canal BPPV, other repositioning techniques may also be used. The maneuver is performed by the physician during the examination, and most patients improve markedly within one or two sessions.
Medication and Other Approaches
Medication does not eliminate BPPV; however, it can be used for a short time to temporarily ease the nausea and unsteadiness that accompany an attack. Long-term use of medication is not recommended, because it can adversely affect the compensation mechanisms of the central nervous system that maintain balance. In cases that do not improve after the maneuvers or that recur frequently, vestibular rehabilitation exercises may help; in very rare, resistant cases, surgical options may be considered.
Recovery and Follow-up
After a successful repositioning maneuver, the spinning sensation decreases rapidly or disappears completely in most patients. Some patients may be left with a mild sense of unsteadiness lasting a few days after the maneuver; this is part of the process by which the inner ear and the brain adapt to the new situation, and it usually resolves on its own. On the first day after the maneuver, patients may be advised to pay attention to head position and to avoid sudden, rapid head movements.
If complaints persist despite treatment or recur within a short time, the examination is repeated, the affected canal is re-evaluated and the maneuver is repeated when necessary. In some patients BPPV can recur months or years later; this recurrent course is an inherent feature of the condition, and each recurrence can be treated successfully with the same methods. In dizziness attacks accompanied by hearing loss, ringing in the ear or neurological findings, however, follow-up is needed for a detailed additional evaluation.
Coping with BPPV in Daily Life
Because BPPV attacks can occur at unexpected moments, some simple precautions can help reduce the risk of falls and injury until the diagnosis is made and treatment is given. When getting out of bed, it is recommended to first turn onto your side and move slowly into a sitting position instead of sitting up suddenly, to make head movements gradually rather than abruptly, and to hold on to something stable when you feel dizzy. Activities that require attention, such as driving, should be postponed while attacks are frequent and until the diagnosis is clear.
After treatment, most patients can return to their daily activities within a short time. However, it should be remembered that BPPV can recur, and if similar dizziness attacks appear again, you should return for an examination without delay. Regular physical activity, balance exercises and keeping underlying risk factors (for example migraine or inner-ear diseases) under control can help reduce how often recurrences occur.
When Urgent Evaluation Is Needed
Although dizziness is usually explained by a benign cause such as BPPV, evaluation should not be delayed when certain findings are present. Sudden-onset, severe spinning lasting for hours, loss of balance to the point of being unable to walk, confusion, or accompanying chest pain, palpitations or severe headache call for a more detailed evaluation, especially in patients with cardiovascular disease or risk factors for stroke. In such situations it is important that the patient be directed to the emergency department or the relevant specialist as soon as possible.
Distinguishing BPPV from Other Causes of Dizziness
In patients with dizziness, the differential diagnosis includes, besides BPPV, Ménière’s disease, vestibular neuritis, migraine-associated dizziness and causes originating in the central nervous system. In Ménière’s disease, spinning attacks are usually accompanied by ringing in the ear, a feeling of fullness in the ear and fluctuating hearing loss; in vestibular neuritis, the spinning sensation can last for days and is continuous rather than positional. Distinguishing these conditions is very important for choosing the right treatment approach, which is why a detailed history must be taken and evaluated together with the examination findings.
Frequently Asked Questions
Is BPPV a dangerous disease? BPPV itself is not a dangerous disease, but care is needed because a sudden, severe spinning sensation can increase the risk of falling.
Are displaced crystals treated with surgery? No; the mainstay of treatment is the repositioning maneuvers performed during the examination. Surgery is considered only in very rare, resistant cases.
Does the dizziness go away completely after the maneuver? Most patients improve markedly after one or a few sessions, but in some patients a mild sense of unsteadiness may last for a few days.
Can BPPV come back? Yes, it can recur over time, especially when risk factors persist; if it recurs, the same treatment methods can be applied again.
Is all dizziness BPPV? No; dizziness accompanied by hearing loss, ringing in the ear, severe headache or neurological findings may point to different causes and requires a separate evaluation.
For the summary:
Back to the short articleThis article is for general information purposes only; please consult your physician for diagnosis and treatment.