Benign paroxysmal positional vertigo diagnosis and treatment

Ross Hauser, M.D.

This article continues and provides further discussion and information on cervical vertigo. Please refer to my other articles

An October 2022 paper (1) from the Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Osaka, Japan gives us the latest insights into the problem of Benign paroxysmal positional vertigo. A summary and brief explanatory notes of this paper are below.

“Benign paroxysmal positional vertigo (BPPV) is characterized by positional vertigo (brief attacks of rotatory vertigo triggered by head position changes in the direction of gravity) and is the most common peripheral cause of vertigo. There are two types of BPPV pathophysiology: canalolithiasis and cupulolithiasis. In canalolithiasis, otoconial debris is detached from the otolithic membrane and floats freely within the endolymph of the canal.”


Explanatory Note: This debris inside your ear are tiny crystals of calcium carbonate (the stuff that antacids are made of). They are sometimes referred to as “ear rocks” as a more descriptive and understandable term than the more medical “otoconial.” The problem is caused by these rocks floating into the ear canals. More precisely these ear rocks detached from the otolithic membrane (the tissue in the vestibular system of the inner ear that helps the brain understand equilibrium) and floats freely within the endolymph (the fluid of the inner ear). Further broken down into posterior-canal-type BPPV and lateral-canal-type BPPV.

Posterior canal type BPPV

  • Posterior canal BPPV is considered the most common of the BPPV diagnosis. The above mentioned rocks float into the back of the ear canal. Patients describe a brief (10-15 seconds) vertigo during changes in head position. The changes in head position can be going from upright to laying flat as in getting into bed or sitting up from a laying down position. Other common head movements include looking up or down.
  • A modified Epley maneuver (head turning and rotation) is commonly used.
  •  The Dix-Hallpike test is a positioning nystagmus test used for diagnosis of posterior-canal-type BPPV.
    • According to the researchers: “When the Dix-Hallpike test is repeated, positional nystagmus and the feeling of vertigo typically become weaker. This phenomenon is called BPPV fatigue. The effect of BPPV fatigue typically disappears within 30 min, (note: the symptoms return) at which point the Dix-Hallpike test again induces clear positional nystagmus even though BPPV fatigue had previously caused the positional nystagmus to disappear.”

Lateral-canal-type BPPV

  • Lateral canal BPPV is considered the second most common of the BPPV diagnosis. The above mentioned rocks float into the lateral areas of the ear canal.
  • The head roll test is a positional nystagmus test used for diagnosis of lateral-canal-type BPPV.


In cupulolithiasis, the otoconial debris released from the otolithic membrane settles on the cupula of the semicircular canal and the specific gravity of the cupula is increased.

Explanatory note: The cupula is the membrane covering the crista ampullaris of the semicircular canal The crista ampullaris senses the rotation of the head and helps convey messages to the brain to maintain balance.

The researchers of this study point out that during the medical examination of a patient with suspected BPPV, questions regarding the characteristics of vertigo, triggered movement of vertigo, duration of vertigo and cochlear symptoms during vertigo attacks are important for the diagnosis of BPPV.

The canalith repositioning procedure

The canalith repositioning procedure can move the ear rocks or debris to other parts of the ear where they cause no symptoms. The procedure involves several simple head movements. The canalith repositioning procedure for posterior canal type BPPV is called the Epley maneuver, and the CRP for lateral canal type BPPV is called the Gufoni maneuver.

When Benign paroxysmal positional vertigo treatment procedures do not work

We are going to go now to a July 2022 study in the journal European archives of oto-rhino-laryngology (2) that investigated the risk factors for residual dizziness (RD) in patients with benign paroxysmal positional vertigo (BPPV) after successful repositioning procedures.

In this review of 4487 patients the prevalence of residual dizziness (RD) was 43.0%.

Factors for residual dizziness included:

  • Age
  • Being female
  • Secondary benign paroxysmal positional vertigo (caused by something other than floating rocks),
  • A longer duration of BPPV before treatment.
  • Abnormal ocular vestibular evoked myogenic potential (testing to check for brain stem lesions)
  • Abnormal cervical vestibular evoked myogenic potential (in simpliest terms cervical spine muscle spasms or irregularities sensed on testing)
  • Higher Dizziness Handicap Index (testing done before treatment to determine the impact of dizziness on quality of life)
  • Anxiety
  • Osteopenia
  • Dizziness started during winter months

The researchers here concluded: “Despite successful treatment, nearly half of the BPPV patients developed residual dizziness (RD). RD seems to be a syndrome caused by multiple factors.”

“Despite successful treatment, nearly half of the BPPV patients developed residual dizziness. Residual seems to be a syndrome caused by multiple factors.”

Let’s focus on the above study and their findings that:

  • Secondary benign paroxysmal positional vertigo (caused by something else).
  • Abnormal ocular vestibular evoked myogenic potential (testing to check for brain stem lesions.)
  • Abnormal cervical vestibular evoked myogenic potential (in simplest terms cervical spine muscle spasms or irregularities sensed on testing).

Physical therapy, the diagnosed Benign paroxysmal positional vertigo patient and the patient who may have suspected Benign paroxysmal positional vertigo but have not been diagnosed.

A paper in the December 2022 edition of the Annals of medicine (7) has researchers evaluating the clinical characteristics of patients with dizziness who were referred by their general practitioner or ENT specialist for vestibular rehabilitation (to help the patient stabilize their posture and gaze stability to improve vertigo symptoms) at a primary care physiotherapy practice. Additionally, the researcher evaluated the patient’s treatment outcomes and looked for prognostic factors for treatment success.

  • Patients were labelled as having Benign paroxysmal positional vertigo or were not labelled with BPPV but displaying similar symptoms. The researchers noted that in the non-BPPV diagnosed patients: ” . . . analysis showed that from the history taking the description of the dizziness symptom (vertigo versus light-headedness), provocation of the dizziness by movements, and a short duration of the dizziness attack were highly suggestive of BPPV.”
    • “The majority of patients reported a spinning sensation which can be regarded as vertigo. However, not all patients with this symptom pattern were designated as BPPV patients.
    • It is known that patients experience difficulty in consistently describing their symptoms, and symptom description alone is not sufficient to guide diagnostics. Hence, positional tests need to be conducted as well.”
  • The researchers noted these characteristic symptoms: “As accompanying symptoms of their dizziness, patients reported primarily nausea, but also head and neck pain. These symptoms were only taken into account if they were more present during the episode of dizziness than in the period before. The concomitant neck pain can be a secondary symptom when patients keep their heads still to avoid provoking the dizziness in a head-on-trunk stiffness reaction.” In this last sentence the researchers noted that neck pain  could be a result of muscle spasms or “stiffness reaction.” In other words, something is unstable and the trunk, torso, and neck are trying to stabilize the spine.

The physical therapist was sending patients back to their doctors for further evaluation. Listen to what the research team said: “Despite . . .prior medical screening, one-third of patients without BPPV (diagnosis) were sent back to the referring doctor for further evaluation. This illustrates the complexity of dizziness and the need for interdisciplinary collaboration.”

Cervical spine instability and recurrent benign paroxysmal positional vertigo

In the above study I commented: that neck pain could be a result of muscle spasms or “stiffness reaction.” In other words, something is unstable and the trunk, torso, and neck are trying to stabilize the spine.

Compression on the brainstem and muscles spasms in the neck are characteristic of cervical spine instability. Not only can cervical spine instability cause dizziness and vertigo it can cause a myriad of symptoms.

This is an email we received, it has been edited for clarity:

“I woke up with sudden motion sickness and nausea after turning over in bed one morning. Upon fully standing and walking that same morning, experienced severe dizziness and room tilting, not spinning, as if a force was pushing me over. In the last months, have also experienced: severe headaches including pressure and tension, pins and needles or tingling, pain in face and teeth; difficulty sneezing; eye pain, eye strain, difficulty reading, light sensitivity; ear pain in and surrounding the ear, feelings of ear fullness, fluid in ears, ear ringing, sound sensitivity; tightness in throat, sometimes difficulty breathing; dizziness, feeling “off,” unsteady, wobbly, feeling like I might fall; depersonalization , derealization, disassociation, or general trouble of being present, being myself or comprehending reality. Recently experiencing more neck pain and irritation, neck muscles are tight and sore, and by the end of the day difficult to hold head up. These are all intermittent and unpredictable.”

The connection between cervical spine instability and recurrent benign paroxysmal positional vertigo is not without its controversies. An April 2022 paper in the  European archives of oto-rhino-laryngology (3) explored possible associations between cervical spine mobility, measured by cervical range of motion and a possible earlier onset of recurrent benign paroxysmal positional vertigo (BPPV), as well as an increased failure rate of canalith repositioning procedures.

  • Medical records of 749 patients with a first-time diagnosis of non-traumatic BPPV were included in this retrospective study. The patients were divided into three groups of varying degrees of cervical spine range of motion.
    • A significant increase in the incidence of recurrent BPPV was found in patients with reduced cervical range of motion
    • According to the researchers: “The results from this retrospective analysis unveiled the previously unexplored relation between reduction in cervical spine mobility and BPPV recurrence and treatment failure. The data from this study do not indicate the mechanisms by which this comorbidity might directly cause recurrent BPPV. However, they may suggest cervical range of motion to be evaluated, in association with other known risk factors for increased susceptibility to BPPV recurrence.”

A March 2022 study in the Ear, nose, and throat journal (4) also reviewed risk factors for Benign paroxysmal positional vertigo’s high recurrence rate. They found higher risk in patients who were:

  • Female gender
  • Over age 65
  • Had high cholesterol or hyperlipidemia
  • Diabetes
  • Hypertension
  • Otitis media
  • Migraine, cervical spondylosis, osteopenia/osteoporosis, head trauma, abnormal vestibular evoked myogenic potential, and long use of computers.

Estrogens and Benign paroxysmal positional vertigo

Why the female gender? A February 2022 paper in the journal Current opinion in neurology (5) records that “recent work has identified a direct link between aberrant gonadal hormone levels and vestibular dysfunction. Benign paroxysmal positional vertigo research suggests that the disorder may be linked to the rapid decrease in estrogen, observed in menopausal women, which disrupts otoconial metabolism within the inner ear.”

A July 2022 paper in the journal Endocrine practice (6) writes of a high incidence of benign paroxysmal positional vertigo is reported in postmenopausal women, and the association between estradiol (E2) deficiency and the occurrence of BPPV has been made which may be a potential risk biomarker for postmenopausal women.

Now let’s center on problems identified as risk factors and found in the cervical spine

  • Cervical spondylosis (cervical spine degenerative disc disease).
  • Abnormal ocular vestibular evoked myogenic potential (testing to check for brain stem lesions.)
  • Long use of computers. Please see my article Forward Head Posture and Text Neck.

Cervical Spondylosis is an umbrella term used to describe degenerative changes in the cervical spine when there is no clear answer as to why you or a particular patient continues to suffer from any one of a long list of symptoms. Cervical Spondylosis has been implicated in problems of dizziness, vision problems, headaches, numbness or pins and needles sensation on one side of their face. Patients will tell us about fainting or nearly passing out from turning their head one way or another and problems we attribute to Vertebrobasilar insufficiency.

Cervical spondylosis is a non-specific degenerative process of the cervical spine, which can cause varying degrees of stenosis of both the central spinal canal and intervertebral neural foramina. Factors contributing to this narrowing include degenerative disc, osteophytes, and hypertrophy of the lamina, articular facets, ligamentum flavum, and posterior longitudinal ligament.

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We hope you found this article informative and it helped answer many of the questions you may have surrounding Benign paroxysmal positional vertigo diagnosis and treatment. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

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1 Imai T, Inohara H. Benign paroxysmal positional vertigo. Auris Nasus Larynx. 2022 Apr 3. [Google Scholar]
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This article was updated August 17, 2022



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