Vertigo and BPPV: Symptoms, Causes, Treatment, and When to Get Help

Vertigo is the feeling that you, or everything around you, is spinning. The NHS describes it as more than just feeling dizzy, because the spinning is strong enough to affect your balance [1]. An attack can last a few seconds or several hours, and severe vertigo can go on for days or even months, though it often gets better without treatment [1].

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo seen by clinicians, according to NICE guidance for UK primary care [3]. This guide is for adults.

When Vertigo Is an Emergency

Most vertigo is caused by inner ear problems, but vertigo can sometimes be a sign of a stroke [1][9][10]. Emergency advice is listed by country.

UK (NHS): Call 999 or go to A&E if you have vertigo with any of the following [1]:

• Double vision or loss of vision
• Hearing loss
• Trouble speaking
• Weakness, numbness or tingling in an arm or leg

The NHS says not to drive yourself to A&E [1]. Its stroke page adds that feeling dizzy or falling over, a severe headache, and blurred vision or loss of sight can also be signs of a stroke, and that you should call 999 even if the symptoms stop [10].

US (CDC): The Centers for Disease Control and Prevention (CDC) says to call 911 right away for sudden trouble walking, dizziness, or loss of balance or coordination; sudden trouble seeing; sudden numbness or weakness in the face, arm or leg; sudden confusion or trouble speaking; or a sudden severe headache [11]. The CDC advises calling for an ambulance rather than driving to hospital, and says symptoms that pass still need care right away [11].

A note on headache: The NHS vertigo page lists vertigo with a severe headache under urgent GP or NHS 111 advice [1], while the NHS stroke page and the CDC treat a sudden severe headache as a possible stroke sign [10][11]. If a severe headache comes on suddenly, or comes with any other stroke sign, treat it as an emergency.

Urgent but not emergency (NHS): Ask for an urgent GP appointment or contact NHS 111 if you have vertigo with being sick or feeling very sick, or a very high temperature or feeling hot and shivery [1]. See a GP if vertigo will not go away or keeps coming back [1].

For more on recognising a stroke, see Stroke Warning Signs: Early Symptoms and When to Act.

What BPPV Is

NICE describes BPPV as a disorder of the inner ear that causes repeated episodes of vertigo when you change the position of your head [3]. The inner ear contains small fluid-filled tubes called semicircular canals, which help you sense movement. ENT UK explains that in BPPV, tiny calcium crystals come loose and drift into these canals [4]. The National Institute on Deafness and Other Communication Disorders (NIDCD) says the loose crystals send the brain incorrect signals about the position of your head [5]. Cochrane describes the debris as continuing to move after your head has stopped, which is why the spinning happens [7].

Symptoms and Triggers

A BPPV episode is usually short and intense. ENT UK says the spinning lasts from a few seconds to a couple of minutes [4]. NIDCD and NICE describe common triggers [3][5]:

• Rolling over or turning in bed
• Looking up
• Bending down or bending over
• Tilting your head to look over your shoulder

Causes and Who Gets It

ENT UK says that in most cases the reason BPPV starts is unknown [4]. When a cause is found, NICE lists [3]:

• A head injury
• Lying down for a long time, for example at the dentist or hairdresser
• Ear surgery
• An earlier episode of another inner ear condition, such as vestibular neuronitis, labyrinthitis or Meniere's disease

NIDCD adds that BPPV can develop simply with getting older [5]. NICE says it can happen at any age but most often starts between the 40s and 60s, and that women are affected more often than men [3].

How BPPV Is Diagnosed

Diagnosis is usually based on your symptoms and a simple test. NICE guidance for UK primary care says a clinician should confirm that the vertigo is brought on by specific head movements, and may use a test called the Dix-Hallpike manoeuvre [3]. The NHS says a GP may do a simple test that moves you quickly from sitting to lying down, which can bring on the symptoms [1]. The clinician will also think about other possible causes, such as Meniere's disease, vestibular neuronitis or an anxiety disorder [3].

Scans are usually not needed. NICE says an MRI or CT scan is not required to confirm BPPV, and is used only when another condition needs to be ruled out, for example if eye movements look unusual or there are other neurological symptoms [3]. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 2017 guideline for adults also aims to reduce unnecessary imaging and other tests [6].

Treatment

Waiting It Out

BPPV often settles without treatment. NICE says clinicians should discuss watchful waiting, while explaining that treatment may help symptoms go away faster [3].

Repositioning Manoeuvres

The main treatment is a particle repositioning manoeuvre, a set of head movements done in a set order. The best known is the Epley manoeuvre [3][5][7]. NICE also mentions Brandt-Daroff exercises as an option to consider [3].

A Cochrane review of 11 trials with 745 adults, with evidence up to January 2014, found that the Epley manoeuvre is a safe and effective short-term treatment for the most common type of BPPV, which affects the back (posterior) canal [7]. It worked better than a fake procedure or no treatment, and about as well as other manoeuvres [7]. In one study, a single Epley manoeuvre worked better than a week of Brandt-Daroff exercises [7]. Nausea during the manoeuvre was reported by 16.7% to 32% of people, with no serious side effects, though some people could not tolerate it because of neck problems [7].

NIDCD says a specialist may perform the manoeuvre, and that one session often works, though some people need several [5].

Can You Do the Epley Manoeuvre at Home?

Sources differ here. Cochrane and NIDCD describe the Epley manoeuvre as something done by a doctor or trained health professional [5][7]. ENT UK says a home version can be a safe alternative to having it done in clinic, with caveats [4][8]:

• Ask your doctor to confirm that you have BPPV and that the home manoeuvre is safe for you first
• You may need to avoid it if you have certain neck, joint, heart or eye problems
• Have someone with you
• Do not drive while you are dizzy
• Contact your doctor if you are not better after 4 weeks

ENT UK says about half of people improve after one home manoeuvre, and others repeat it daily for a few weeks [4]. Ask your clinician to show you the technique before trying it at home.

Medicines

Medicines are not the main treatment for BPPV. NICE says medicines to ease symptoms are not usually helpful [3], and the AAO-HNS guideline aims to reduce inappropriate use of vestibular suppressant medicines, which dampen the balance system [6].

Follow-Up and Referral

NICE advises a review after 4 weeks if symptoms have not gone [3]. It recommends referral to a balance specialist if symptoms are unusual, have not settled within 4 weeks, or keep returning after repeated manoeuvres [3]. NICE also says hospital admission may be needed if someone is vomiting severely and cannot keep fluids down [3].

Will It Come Back?

BPPV often returns. NICE describes it as relapsing and remitting, with recurrence common [3], and ENT UK says symptoms may come back weeks or years later [4]. In the Cochrane review, about 36% of people had a recurrence after treatment [7]. If symptoms return, speak to your clinician.

How BPPV Compares With Other Inner Ear Causes

The NHS lists several inner ear problems that cause vertigo [1][2][9]. This short comparison is based on NHS descriptions.

The NHS says labyrinthitis and vestibular neuritis often start suddenly and ease over a few days, with balance returning over 2 to 6 weeks [2]. It advises an urgent GP appointment or NHS 111 for sudden hearing loss in one ear [2]. The NHS also names migraine and some medicines as possible causes of vertigo [1].

For related ear problems, see Tinnitus: Causes, When to Worry, and What Helps and Ear Infection in Adults: Symptoms, Causes, and When to See a Doctor.

Coping During an Episode

The NHS suggests these steps while vertigo is active [1]:

• Lie still in a quiet, dark room
• Move your head slowly and carefully
• Sit down straight away when you feel dizzy
• Turn the lights on if you get up at night
• Get out of bed slowly
• Squat rather than bend over to pick things up
• Avoid stretching your neck to reach up high

Driving in the UK: The NHS says you must tell the Driver and Vehicle Licensing Agency (DVLA) if you have vertigo [1].

Conclusion

If head movements keep setting off short bursts of spinning, book a GP or clinician visit rather than living with it. Avoid driving while dizzy, and seek emergency help straight away if vertigo comes with any stroke warning sign.

Medical Disclaimer

This article is for general information and does not replace advice from a qualified health professional. If you have vertigo with any stroke warning sign, call emergency services straight away.