Benign Paroxysmal Positional Vertigo

 

Benign paroxysmal positional vertigo (BPPV) causes short episodes of intense dizziness (lasting for seconds to minutes) usually triggered by a change in head position.  BPPV is thought to be caused by tiny solid fragments (otoconia) in the inner ear labyrinth. In many cases the condition gets better on its own after several weeks

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Signs and symptoms

Typically:

  1. Symptoms are brought on by specific movements and positions of the head relative to gravity. People may modify their movements to limit symptoms
  2. Vertigo occurs in transient episodes (typically lasting less than 1 minute), which are preceded by position change, with the person being asymptomatic between attacks
  3. Nausea and vomiting may occur
  4. Light-headedness and imbalance are sometimes reported and can persist for longer than the vertigo episode
  5. Hearing is not affected (although hearing impairment may coexist for a different reason)
  6. Tinnitus is not a feature of benign paroxysmal positional vertigo

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Assessment

Examine the person to elicit signs suggestive of a diagnosis of benign paroxysmal positional vertigo and exclude other conditions:

  1. Examination is likely to be normal at rest in a sitting position
  2. Perform a full ENT, cardiovascular, and neurological examination to exclude other causes of Vertigo
  3. Diagnose posterior semi-circular canal BPPV if the Dix-Hallpike manoeuvre provokes vertigo and torsional (rotatory) upbeating nystagmus.  To view a demonstration of Dix-Hallpike Testing, click here
    1. There is a latent period (usually of 5 to 20 seconds) between completing the manoeuvre and onset of vertigo and nystagmus
    2. The vertigo and nystagmus increase in intensity, then decline, but should resolve within 1 minute of nystagmus onset
    3. Less intense nystagmus in the opposite direction may occur for a short time on sitting upright
  4. If the Dix-Hallpike manoeuvre is negative, repeat in one week

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NOTE Investigations are not usually required to confirm diagnosis

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Exclusion of Red Flag Symptoms

Cerebellar signs should be excluded:

  • Dysdiadochokinesia (DDK)
  • Past-pointing
  • Limb/trunk/gait ataxia
  • Dysarthria

Refer to the Stroke or Neurology Department as appropriate

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NOTE Syncope is not a feature of BPPV and should be excluded

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Patient advice

Advise the patient:

  1. Most people recover over several weeks, even without treatment, but symptoms can last much longer and may recur
  2. A simple repositioning manoeuvre can help alleviate their symptoms in most cases
  3. To get out of bed slowly and to avoid tasks that involve looking upwards
  4. Not to drive when they are dizzy, or if they might experience an episode of vertigo while driving
    1. The Driver and Vehicle Licensing Agency (DVLA) states that people with 'liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness' should stop driving and inform the DVLA
    2. However, experts suggest that, in general, BPPV is not spontaneous or unprovoked and most people with this condition continue to drive
  5. Inform their employer if their vertigo poses a risk in the workplace (for example if they use ladders, operate heavy machinery, or drive a vehicle)

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Discuss the risk of falling in the home during an episode of vertigo and suggest measures to reduce this

Offer the person written information about BPPV

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Management

NOTE:  Treatment depends on the severity of symptoms.  Reassurance that most people recover over several weeks may be enough for those patients with mild symptoms

Discuss the option of watchful waiting to see whether symptoms settle without treatment. Explain that treatment may help the person's symptoms resolve more quickly

If the person prefers treatment:

  1. Offer a particle (canalith) repositioning manoeuvresuch as the Epley manoeuvre. Ideally, this should be done at the first presentation in primary care if the expertise and time are available, but if performed warn patient they may not be able to drive afterwards. To view a demonstration of a canalith repositioning manoeuvre, please click here
    1. Symptoms may improve shortly after treatment, but full recovery can take days to a couple of weeks
    2. If symptoms do not settle after 1 week and the diagnosis of BPPV is not in doubt, advise the person to return and consider repeating the Epley manoeuvre
    3. The Semont manoeuvre is an alternative if the skills to perform it are available, but it is less commonly used in primary care
  2. Consider suggesting Brandt-Daroff exercises which the person can do at home, particularly if the Epley manoeuvre cannot be performed immediately or is inappropriate.  For more information see the Brandt Daroff Exercises Patient Leaflet
  3. Symptomatic drug treatment is not usually helpful for people with BPPV
    1. Use of vestibular sedatives (e.g. Buccastem) should only be reserved for severe cases and for short duration of use only e.g. 3-5 days, as it can delay recovery

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Advise the person to return for follow up in 4 weeks if symptoms have not resolved in case BPPV has been incorrectly diagnosed

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Admission or referral

Admit the person to hospital if they have severe nausea and vomiting and are unable to tolerate oral fluids

Refer to a medically qualified balance specialist (such as an ENT specialistaudiovestibular specialist physician; or care of the elderly physician with a special interest) if any of the following apply:

  • The expertise to provide a canalith repositioning procedure (for example the Epley manoeuvre) is not available in primary care
  • Physical limitations affect the safety or practicality of carrying out canalith repositioning procedures in primary care
  • A canalith repositioning procedure (for example the Epley manoeuvre) has been performed and repeated, and symptoms are still present
  • Symptoms or signs are atypical
  • Symptoms and signs have not resolved in 4 weeks
  • Refractory cases or if diagnostic uncertainty - refer to the Balance Clinic
  • There have been three or more periods during which the person has experienced episodes of vertigo

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For more information on when to refer other people with the symptom of vertigo, including red flag features for urgent referral, see the CKS topic on Vertigo

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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