BPPV — Benign Paroxysmal Positional Vertigo
UK primary care pathway · RCGP SCA preparation · Dix-Hallpike & Epley
Progress0 / 9
The full reasoning pathway — BPPV is diagnosed at the bedside with Dix-Hallpike and treated with Epley; confirm there are no central features first. Reassure, give home exercises, and safety-net.StartDecisionInvestigateActionReferStop / Admit
PresentationPositional vertigo
Brief (seconds) spinning triggered by head movement (rolling over, looking up). No persistent hearing loss or neurology.
Step 1 · Safety — central featuresAtypical or central features?
Persistent vertigo, new headache, focal neurology, atypical/direction-changing nystagmus → reconsider central cause.
Home Brandt-Daroff exercises if symptoms persist after Epley; reassure that BPPV is benign and self-limiting. Get up slowly and avoid sudden head movements during a flare; falls-proofing (lighting, clutter, footwear) in older patients. Sleep slightly propped for a night or two after Epley. Avoid long-term vestibular sedatives (they prolong symptoms and add falls risk).
Step 9 · review & safety-net
Step 9 · Review & safety-netRecheck & when to escalate
Review at 1–2 weeks — repeat the Epley if still positive; recurrence is common and can be re-treated. Reassess / refer if symptoms persist despite repeated manoeuvres, or central features emerge — constant (non-positional) vertigo, new headache, focal neurology, direction-changing or vertical nystagmus, or inability to walk (posterior-circulation stroke → urgent). Advise re DVLA if vertigo could occur while driving.
⚠️ Treat at the bedside: BPPV responds to the Epley manoeuvre, not to long-term prochlorperazine — which only prolongs symptoms and risks falls in older patients.
1
Safety
Exclude Central & Sinister Causes Before Diagnosing BPPV
BPPV is benign and common, but the examiner is testing whether you can confidently separate it from a posterior-circulation stroke and other dangerous mimics.
Central vertigo (stroke) Vertical/direction-changing nystagmus, new headache, diplopia, dysarthria, dysphagia, limb/gait ataxia, or HINTS suggesting central → 999.
Continuous (not positional) vertigo Sustained spontaneous vertigo lasting hours/days is NOT BPPV — consider neuritis, stroke, or other cause.
New unilateral hearing loss Sudden SNHL with vertigo → same-day ENT (exclude labyrinthine infarct / SSNHL needing steroids within 72h).
Acute focal neurology Any new weakness, sensory loss, visual field defect → stroke pathway.
Severe headache / trauma Thunderclap headache or recent significant head injury with vertigo → urgent assessment.
Unsteady between attacks Persistent imbalance or falls beyond brief positional episodes → reconsider diagnosis.
The key safety task in positional vertigo is excluding a central cause: BPPV produces brief (<1 minute), fatigable, position-triggered vertigo with a characteristic torsional-upbeat nystagmus, whereas central lesions give sustained or direction-changing/vertical nystagmus and other neurological signs. Misclassifying a cerebellar stroke as BPPV is the catastrophic error this pathway guards against.
2
Diagnose
History — The Hallmark Pattern
The history alone usually points to BPPV; confirm with positional testing.
Trigger
Vertigo provoked by head-position change — rolling over in bed, lying down, looking up (“top-shelf vertigo”), bending forward.
Duration
Brief — typically <30–60 seconds per episode, settling when the head is still.
No cochlear symptoms
No hearing loss, tinnitus or aural fullness (their presence suggests Ménière’s or other pathology).
Associated
Nausea common; vomiting less so. Patients often anxious and avoid the provoking position.
Risk factors
Older age, prior head trauma, vestibular neuritis, prolonged recumbency, osteoporosis/low vitamin D (recurrence).
Exclude mimics
Ask about continuous vertigo, neurological symptoms, migraine features (vestibular migraine), and medication-related dizziness.
Posterior canal BPPV — the commonest type — is caused by displaced otoconia (canaliths) stimulating the cupula during head movement. The combination of brief, position-triggered vertigo with no auditory symptoms and normal neurology between attacks is highly specific, and reliably distinguishes BPPV from Ménière’s, neuritis and central causes.
3
Diagnose
Examination — Dix-Hallpike & HINTS
Positional testing confirms the diagnosis and identifies the affected canal; a focused neuro/otological exam excludes central disease.
Dix-Hallpike Posterior canal
From sitting, turn head 45° to test side, lay supine with head extended ~20° below horizontal. Positive: latency of a few seconds, then transient up-beating torsional nystagmus and vertigo that fatigues. Identifies the affected ear.
Supine roll test Horizontal canal
If Dix-Hallpike negative but history suggestive — roll head to each side supine to detect horizontal-canal BPPV.
HINTS (if continuous vertigo)
Only valid in acute continuous vertigo: normal head-impulse + direction-changing nystagmus + skew = central → urgent. Not used for episodic BPPV.
Otoscopy & hearing
Normal in BPPV; unilateral hearing loss points elsewhere.
Cerebellar/gait
Finger-nose, heel-shin, Romberg, gait — should be normal between episodes.
Cautions
Care with Dix-Hallpike in severe cervical disease, carotid disease, or recent neck injury.
A positive Dix-Hallpike with the classic latent, fatigable, torsional up-beating nystagmus is effectively diagnostic of posterior-canal BPPV and allows immediate treatment with a repositioning manoeuvre — no imaging required. Recognising when to switch to the supine roll test (horizontal canal) and when HINTS applies (continuous vertigo only) marks out competent assessment.
4
Diagnose
Investigations — Usually None
Classic BPPV is a clinical diagnosis requiring no tests. Investigate only to exclude alternatives.
No routine tests
Positive Dix-Hallpike with typical features → proceed directly to repositioning. Imaging is unnecessary and CT poorly visualises the posterior fossa.
MRI brain If central suspected
For atypical nystagmus, persistent symptoms, focal neurology, or unilateral progressive hearing loss (acoustic neuroma) — via appropriate referral.
Audiometry
Only if hearing symptoms — points away from BPPV toward Ménière’s/retrocochlear pathology.
Bloods
Consider FBC, U&E, glucose, vitamin D if recurrent BPPV or to exclude contributors to dizziness.
ECG/lying-standing BP
If pre-syncope or orthostatic symptoms blur the picture.
Over-investigation medicalises a benign, treatable condition and delays the curative manoeuvre. Imaging is reserved for atypical features or red flags; vitamin D testing has emerging relevance because deficiency is associated with higher BPPV recurrence and supplementation may reduce it.
5
Treat
Canalith Repositioning — The Curative Treatment
Particle-repositioning manoeuvres are first-line and highly effective; drugs have little role.
1st lineEpley manoeuvre for posterior-canal BPPV — sequential head positions to move otoconia out of the canal. ~80% resolve after one manoeuvre, >90% within three. Can be performed in the consultation.
Self-treatmentBrandt-Daroff exercises or patient-performed Epley taught for home use, especially for recurrence or incomplete response.
Horizontal canalLempert (BBQ) roll or Gufoni manoeuvre — refer if not trained.
AvoidDo not rely on vestibular sedatives (e.g. prochlorperazine) — they do not treat BPPV, impair central compensation, and increase falls; at most very short-term for severe nausea.
Refer if refractoryENT/vestibular physiotherapy if BPPV persists after repeated manoeuvres or diagnosis is uncertain.
BPPV is one of the few causes of vertigo with a mechanical cure: the Epley manoeuvre repositions free-floating otoconia and resolves symptoms in the large majority. Vestibular suppressants are a common error — they neither cure BPPV nor aid recovery and they raise falls risk, so they should be avoided or limited to brief symptomatic use.
6
Refer
Referral Pathways
Most BPPV is diagnosed and cured in primary care. Refer for red flags, uncertainty, or treatment failure.
Emergency
Suspected central cause/stroke, sudden hearing loss with vertigo, or acute focal neurology.
ENT / balance clinic
BPPV not responding to repeated repositioning, frequent recurrence, horizontal-canal BPPV if untrained, or diagnostic doubt.
Vestibular physiotherapy
For repositioning, habituation exercises, and persistent imbalance/falls risk.
Neurology
Atypical nystagmus, suspected central positional vertigo, or coexisting neurological signs.
Primary care manage
Classic posterior-canal BPPV — Dix-Hallpike positive, treated with Epley, safety-netted.
The referral filter is essentially: exclude central disease (emergency), then route the minority with refractory, recurrent, or atypical BPPV to ENT/vestibular services. The bulk of cases need only confident diagnosis, a repositioning manoeuvre, and good safety-netting.
7
Lifestyle
Advice & Self-Management
Reassurance Explain the benign, mechanical nature and excellent prognosis; reduces anxiety and avoidance behaviour.
Home exercises Teach self-Epley/Brandt-Daroff for recurrence; provide written/video instructions.
Falls prevention Address home hazards, especially in older patients; review sedating medications.
Driving & safety Avoid driving/working at heights during active vertigo; resume once controlled. Advise re sudden positional triggers.
Vitamin D Check/replace if deficient — may reduce recurrence in recurrent BPPV.
Expect recurrence Counsel that BPPV recurs in a substantial minority and is re-treatable.
Patient understanding transforms BPPV management: knowing the condition is benign and that home manoeuvres can abort recurrences reduces healthcare use and disability. Falls prevention and medication review are particularly important in the older patients who most commonly present.
8
Treat
Recurrent & Atypical BPPV
Recurrence
Common (up to ~50% over years). Re-confirm with Dix-Hallpike and re-treat; teach self-Epley.
Secondary BPPV
Post head trauma, after vestibular neuritis, prolonged bed rest, or ear surgery — manage as usual, consider underlying cause.
Refractory
Failure after several correctly-performed manoeuvres → ENT/vestibular physiotherapy; reconsider diagnosis (central positional vertigo, vestibular migraine).
Coexisting disease
BPPV may coexist with Ménière’s, migraine, or neuritis — treat each component.
Vitamin D / osteoporosis
Associated with recurrence; optimise where deficient.
Elderly with falls
Have a low threshold to test for BPPV in older fallers — it is a treatable, often-missed contributor.
BPPV in older fallers is frequently overlooked yet readily treatable, making positional testing a high-yield step in falls assessment. Recurrent or refractory cases warrant re-confirmation and, if manoeuvres genuinely fail, reconsideration of central positional vertigo or vestibular migraine.
9
Safety
Follow-Up & Safety-Netting
Immediate
Reassess nystagmus/symptoms after the manoeuvre; many resolve the same visit. Arrange follow-up if symptoms persist.
1–4 weeks
Review response; repeat Dix-Hallpike and manoeuvre if still positive; teach home exercises.
Re-examine if symptoms change
New continuous vertigo, hearing loss, or neurological symptoms → re-triage for central/otological cause.
Safety-net — 999
New focal neurology, severe headache, diplopia, or sustained vertigo with abnormal gait → stroke pathway.
Safety-net — same-day ENT
New unilateral hearing loss with vertigo.
Recurrence plan
Advise patients how to recognise recurrence and perform/seek repositioning.
Safety-netting keeps the benign label honest: any evolution to continuous vertigo, hearing loss or neurological signs must prompt re-assessment for a central or otological cause. Clear recurrence advice empowers patients to manage future episodes with minimal delay.
Educational use only. Pathway based on: NICE CKS BPPV, AAO-HNS Clinical Practice Guideline: BPPV (2017), NICE CKS Vertigo. See also the Vertigo pathway for undifferentiated presentations. Always adapt to individual patient context and local services.