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BPPV (Benign Paroxysmal Positional Vertigo).

Benign Paroxysmal Positional Vertigo (BPPV) is a mechanical condition of the inner ear characterised by a sudden, brief, and intense spinning sensation and dizziness.

BPPV is a condition which usually causes the symptom of vertigo for short periods of time.
It is benign, meaning it is not serious sinister or life threatening, occurs suddenly (paroxysmal) in short episodes usually lasting 10 – 30 seconds, (paroxysmal) and it is correlated to a change in head position (positional) in relation to gravity.

If you experience BPPV you may notice:

  • Dizziness
  • Spinning sensation
  • Light-headedness
  • Unsteadiness
  • Nausea
  • Vomiting
  • Balance problems
  • Nystagmus (uncontrolled flickering of your eyes)
  • Neck stiffness or pain

Common triggers for BPPV include:

  • Rolling over in bed
  • Getting into or out of bed
  • Bending over
  • Looking up
  • Walking and turning head side-to-side in a “yes” movement or “no” movement
  • Driving and turning head from side-to-side or following the traffic with your eyes

What Causes BPPV?

BPPV occurs when the microscopic fragments (otoconia) made up of calcium carbonate crystals that float in the fluid within the middle ear have dislodged from the lining of the labyrinth within the vestibule. If these fragments remain in the vestibule there is no problem. The problem occurs if a fragment gets into one of the three semi-circular canals.

The semi-circular canals (anterior, horizontal and posterior) are at right angles to each other and sense movements of your head: up/down, left/right, forward/back. They assist to control your balance and awareness in space.

The posterior canal is the most common canal that is affected. When your head is still, the dislodged fragment sits at the bottom of the canal. When the head moves the fragment moves within the fluid. This then bombards signals to the vestibular nerve which conflicts with normal messages from the good ear. The brain gets confused as to where it thinks you are in space and causes an intense rush of vertigo.

There is no definitive cause for BPPV, and it is unsure why the fragments dislodge from the inside lining of the labyrinth. However, it most commonly affects:

  • People over the age of 40
  • More women than men
  • Older people

It has been associated with inner ear disorders, degeneration of the inner ear structures, infections and sickness.

How do you treat BPPV?


During your initial assessment, the physiotherapist will go through a thorough history including when the symptoms started, how they started, what symptoms you initially experienced and if they are different to those you are currently experiencing. Further questioning can include more personal health details which are important for an accurate diagnosis

Physical examination will look at:

  • Movements of your neck and head
  • Movements of your eyes
  • Balance assessment
  • Assessing and excluding other important differential diagnosis


An important test which may occur in an initial assessment consultation known as the Dix-Hallpike manoeuvre. This is a quick action of moving your head to one side and lying back down on the treatment table, and it helps confirm or exclude a diagnosis of BPPV.

The Epley Manoeuvre is the main form of treatment performed by Physiotherapists to treat BPPV. This includes four main head and body movements with each position held for approximately 30 – 60 seconds.


Balance exercises: As your balance may be affected by BPPV, balance exercises may be prescribed by your Physiotherapist to improve your symptoms and function

Eye and head movement exercises: You will be prescribed exercises which initially involve gentle movements of your head and eyes. Once your symptoms improve and the exercises become easy, they can be progressed to more challenging exercises

Home management and advice

Once your physiotherapist has diagnosed and treated your condition, you are likely to be sent home with strict advice and self-management, which is important to follow until your symptoms resolve. This will most likely include:

  • Avoid lying on the affected side
  • Sleeping upright at 45 degrees if possible, alternatively if this is not possible, then sleeping on your unaffected side
  • Limiting quick movements of the head
  • Limiting your driving

Neurological Physiotherapy

Sometimes it is also necessary to refer you to a Neurological Physiotherapist. This may be the case if it is determined that your symptoms are not caused by BPPV, or if further assessment is required due to a lack of improvement with treatment.

Neurological Physiotherapists are advanced practitioners in the assessment, treatment, and management of neurological conditions. They have training and knowledge to assess and treat BPPV associated with more complex conditions.

Seeing your GP

  • It is important that your GP is involved in your medical care
  • It is important you discuss your symptoms with your GP so they can also best treat and assist your condition
  • GP’s can prescribe an anti-nausea medication, most commonly Stemetil to assist your symptoms if you have any nausea or vomiting

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