A Deeper look into Vertigo and BPPV (Benign Paroxysmal Positional Vertigo)


In my last blog we talked about the difference between vertigo and dizziness. Now I would like to dive a little deeper into vertigo. Most often people come to see a vestibular therapist like me at Fortius Physiotherapy Niagara because their doctor told them they have vertigo. But what is vertigo? What can cause it??

Vertigo is a symptom, it is not a diagnosis. Just like pain or nausea. It’s a feeling and it doesn’t actually tell you what’s wrong. Vertigo is the sensation that either you are spinning or the room is spinning. You can have vertigo from a number of different sources. For example, vestibular migraines, Meniere's disease, vestibular neuritis, medications, or central issues like a stroke, brain injury or concussion. However, the most common cause of vertigo is BPPV or Benign Paroxysmal Positional Vertigo.

BPPV is the most common form of positional vertigo and it accounts for nearly half of all people with peripheral vestibular system dysfunction. The prevalence of BPPV in the general population is thought to be about 2.4% but the prevalence increases with age. Meaning the older a person is, the more likely they are to get BPPV. It is seven times more common in people over the age of 60 compared to people from 18-39 years of age. In people over the age of 65, the incidence may be as high as 35% to 40%. BPPV is more common in women than men in all age groups.

What is BPPV?

In our inner ear we have organs that detect our head movement. These organs have otoconia or “crystals” that are attached to them that help in this process. It is a natural process for them to dislodge and to be reabsorbed by the body. Just like our hair falls out, or our skin flakes off, our body is constantly replacing itself. However, sometimes when they dislodge, they can migrate into one of the semicircular canals where they don’t belong. If this happens, then the problem is termed BPPV. In BPPV, the dislodged otoconia can move when with certain head movements. This movement of the crystals can trigger a nerve to send inaccurate information to the brain, and therefore creating the sensation of vertigo (spinning), abnormal eye movement (nystagmus) and sometimes nausea.

The head movements that typically provoke the vertigo are looking up, looking down, lying down flat quickly and rolling over while lying down. The vertigo is usually quick onset (less than a minute) and short in duration (less than 60 seconds). It also goes away if the person stays in the provoking position. Common movements in everyday life that can provoke the vertigo associated with BPPV involve turning over in bed, looking up into a cupboard, tilting your head back in a dentist chair or having your hair washed at a salon.

What causes BPPV?

In the majority of cases (35%) there is no known cause of BPPV (idiopathic onset). Prior head trauma, which can be minor, is present in about 15% of cases. In the remainder of cases, BPPV occurs in relationship with a variety of vestibular dysfunctions such as Meniere’s disease, vestibular neuritis/labyrinthitis, and ear surgeries. There is a higher incidence of BPPV in those persons who experience migraine headaches.

How is BPPV assessed?

Typically, two tests will be performed in the clinic to look for the presence of the otoconia in one or more of the semicircular canals. These tests are the Dix-Hallpike and the Head roll tests. Sometimes a different test may be utilized on a case by case basis.

How is BPPV treated?

Most BPPV involves loose or free floating otoconia in the posterior semicircular canal of the vestibular system. Sometimes the otoconia can be in the horizontal canal. The basis of all the treatment techniques is to move or “float” the loose otoconia around the semicircular canal in order to reposition them in the saccule where they belong. The treatment usually takes about 10 minutes. If the otoconia are in the posterior canal (80-90% of all BPPV) then the modified Eply maneuver will likely be used. There are other techniques if necessary and for other canals.

How successful is the treatment?

Fortunately, the various physiotherapy treatment techniques for BPPV are usually very successful. Many studies have demonstrated a success rate of over 80% with one treatment. Some people require multiple treatments and rarely the BPPV can be difficult to resolve.

Can the BPPV recur?

Yes, the BPPV does recur in many people. The recurrence rate has been reported as varying from 18% to 37%. It can recur at any time, although during the first year after treatment, the recurrence rate is the highest.

Will BPPV spontaneously resolve if not treated?

In many cases, BPPV will spontaneously resolve on its own. One study indicated that the spontaneous remission rate might vary from 33% to 50%. However, it might take a long time for the spontaneous remission to occur and if it does not go away on its own, it might be present for many years and may lead to other secondary vestibular issues.

If you have been told you have vertigo, feel like the room is spinning or simply want to learn more about what might be causing your dizziness or balance concerns, then please contact the Fortius Physiotherapy Niagara office to book an appointment.


Jennifer Lapierre PT, DPT
Vestibular Rehabilitation Therapist