Benign paroxysmal positional vertigo (BPPV)

What is it?

Benign paroxysmal positional vertigo, or BPPV, is the most common cause of vertigo. Its name describes it well:

• Vertigo: a feeling that everything is spinning around you, or that you are spinning.
• Positional: it is triggered by moving your head into certain positions.
• Paroxysmal: it starts suddenly and does not last long.
• Benign: it is not a serious illness and does not put your life at risk, even though it feels very unpleasant.

Inside the inner ear there is a balance organ containing microscopic calcium crystals called otoconia. Sometimes a few of them come loose and slip into the semicircular canals, small fluid-filled tubes that sense head rotation. When you change position, the crystals move inside the canal, push the fluid and send the brain a false signal that you are turning. The result is intense but brief vertigo.

In most people the crystals end up in the posterior canal. Less often they affect the lateral (horizontal) canal and, rarely, the anterior canal.

What are the symptoms?

• Vertigo lasting a few seconds, usually less than a minute, when you:
  • lie down or get out of bed,
  • turn over in bed,
  • look up (for example, to hang washing or reach a high shelf),
  • bend down or tip your head back (at the hairdresser’s or the dentist’s).
• Nausea and sometimes vomiting during the attack.
• Unsteadiness or a “floating” feeling that can last hours or days between attacks.

BPPV does not cause hearing loss, a severe headache, or neurological symptoms such as double vision, slurred speech or weakness.

Why does it happen?

In most cases the crystals come loose for no clear reason. It is more common:

• after the age of 50 and in women;
• after a blow to the head;
• after other inner ear problems, such as vestibular neuritis or Ménière’s disease;
• after a long time in bed because of illness or surgery;
• in people with osteoporosis, low vitamin D or migraine.

How is it diagnosed?

The diagnosis is made in clinic, from your history and an examination that takes a few minutes. Blood tests, MRI or CT scans are usually not needed.

• Dix-Hallpike manoeuvre: you sit on the couch with your head turned to one side, and we lie you back quickly with your head slightly over the edge. If BPPV is in the posterior canal of that ear, the vertigo appears for a few seconds.
• Supine roll test: lying on your back, we turn your head to each side to check the lateral canal.

Meanwhile we watch your eyes. The crystals cause a typical involuntary eye movement, called nystagmus, which shows which ear and which canal are affected. Sometimes we use goggles with a camera (video-nystagmoscopy) to see it better.

It is normal to feel dizzy during these tests. That is exactly how the diagnosis is confirmed, and it passes in seconds.

If your history or examination does not fit BPPV, other tests may be needed to rule out other causes of vertigo.

How is it treated?

Repositioning manoeuvres

The effective treatment is a repositioning manoeuvre: a sequence of head and body positions that guides the crystals out of the canal and back to a part of the ear where they cause no symptoms.

• For the posterior canal, the most widely used are the Epley manoeuvre and the Semont manoeuvre.
• For the lateral canal, others are used, such as the Lempert (“barbecue roll”) or Gufoni manoeuvre.

They are done in clinic in about 10 to 15 minutes. They do not hurt, although they can cause brief vertigo and nausea. Most people’s symptoms go away after one to three manoeuvres. Sometimes they need to be repeated at another visit.

Medicines

Anti-dizziness medicines do not cure BPPV. They can help for a day or two if nausea is severe, but long-term use is not recommended: they slow down the recovery of balance and increase the risk of falls.

Other options

• Watchful waiting: BPPV can go away on its own over days or weeks, although manoeuvres usually clear it much sooner.
• Vestibular rehabilitation exercises, such as the Brandt-Daroff exercises, which you can do at home when unsteadiness persists or manoeuvres cannot be done.

After the manoeuvre

• You may feel slightly unsteady for a few days. This is normal and usually settles on its own.
• You do not need to sleep sitting up, wear a neck collar or keep your head still. Current guidelines do not recommend these restrictions.
• Get up slowly, in two steps: first sit on the edge of the bed, wait a few seconds, then stand.
• If you still have vertigo after about four weeks, come back to clinic. The manoeuvre may need repeating, or another cause may need to be considered.

Advice

• Prevent falls, especially if you are older: leave a light on at night, hold the handrail on stairs and avoid climbing chairs or ladders while you are having attacks.
• Do not drive or work at heights while you have vertigo.
• Do not try manoeuvres you have seen online without a diagnosis first. It matters which ear and which canal are affected, and doing the manoeuvre on the wrong side does not help.
• BPPV can come back. It often returns over the years, sometimes in the same ear. If it does, see your doctor: it can be treated just as well.
• If your vitamin D is low, correcting it may reduce relapses. Talk to your doctor before taking supplements.

When to seek urgent help

Some vertigo is not BPPV and can be caused by a problem in the brain. Call 112 (in Spain) or your local emergency number, or go to the emergency department if the vertigo:

• lasts for hours without stopping, even when you keep still;
• comes with a sudden, severe headache;
• comes with double vision, difficulty speaking or swallowing, weakness or tingling on one side of the body, or a drooping face;
• stops you from walking or standing, even without moving your head;
• comes with a sudden loss of hearing;
• starts after a hard blow to the head or with loss of consciousness.

Frequently asked questions

Is it serious? No. It is very unpleasant, but it does not damage the ear or the brain. The main risk is falling during an attack.

Will I lose my hearing? No. BPPV does not affect hearing. If you notice your hearing getting worse, mention it, as it could be a different problem.

Is it caused by my neck? No. This is a common belief, but BPPV starts in the inner ear. That is why it is treated with specific manoeuvres and not with treatments for the neck.

Why does it happen when I turn over in bed? Because in that position the crystals move along the affected canal. That is why the vertigo always comes with the same movements.

Can I do the manoeuvre myself at home? In some cases we can teach you, once we know which ear and which canal are affected. Without that diagnosis, it is not recommended.

References

1. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3 Suppl):S1-S47.
2. Pérez-Vázquez P, et al. Practice guidelines for the diagnosis and management of benign paroxysmal positional vertigo. Otoneurology Committee of the Spanish Society of Otorhinolaryngology consensus document. Acta Otorrinolaringol Esp. 2018;69(6):345-366.
3. von Brevern M, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society. J Vestib Res. 2015;25(3-4):105-117.
4. Xin H, et al. Comparative efficacy and safety of repositioning maneuvers for posterior canal BPPV: a network meta-analysis. Front Neurol. 2026;17:1762375.
5. Imai T, et al. Therapeutic strategies for benign paroxysmal positional vertigo of the Japan Society for Equilibrium Research. Auris Nasus Larynx. 2026;53(4):554-557.
6. Cox H, Frith J. Best practice assessment and management of benign paroxysmal positional vertigo in older adults. Age Ageing. 2025;54(8):afaf225.

For general information only. It does not replace a medical consultation and cannot be used for diagnosis. In an emergency in Spain, call 112.

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