Caused by loose debris floating throughout the inner ear, benign paroxysmal positional vertigo (BPPV) can cause acute attacks of vertigo with changes in head position.


BPPV is a condition characterized by episodes of vertigo exacerbated by changes in head position such as going to lie down in bed, rolling over in bed, or looking up or down. The episodes typically last for seconds to minutes and are better with keeping the head still in neutral position.


The term “loose crystals” is used frequently to describe the calcium carbonate crystals or otoliths that have broken loose from an area of the inner ear called the utricle. These crystals are attached to the utricle and help us sense gravity in a linear fashion (i.e. moving forward or backwards). Head trauma, a current or old inner ear infection, or other inner ear disorders such as Meniere’s disease may cause the crystals to break off from the utricle. If the crystals get into the semicircular canals it can cause a positional vertigo. There are hair cell bundles called cupula that sit at the end of these semicircular canals that are very sensitive to movement of fluid. Imagine a snow globe representing your head position and then turn it upside down. Even though your head is still, the “loose crystals” are still moving and stimulating the cupula to move thus telling your brain that you are moving when you are actually not. This discord causes the vertigo sensation and may also lead to nausea and vomiting.


Diagnosis & Treatment

BPPV is diagnosed by looking for abnormal eye movements called nystagmus, which is recorded in our office with infrared video oculography. These eye movements are recorded and shown to you so that you can see “before and after” results of treatment. There is a reflex pathway from the hair cells in the inner ear to the muscles around the eyes. We can infer which ear and which canal is being irritated by watching eye movements with your head placed in positions that may exacerbate symptoms (i.e. Dix-Hallpike Maneuver). The treatment protocol is decided after studying these eye movements.


Treatment of BPPV involves placing your head and body in certain positions to “roll the crystals out of the canal” and back into the area where they came from (the vestibule). These maneuvers are called canalith repositioning maneuvers such as the Epley maneuver. After treatment, we record your eye movements again in the same head position that had previously caused symptoms of vertigo. If the eye movements resolve and your symptoms have markedly improved, the BPPV has been treated.



Some things you should avoid until your follow-up:

  • Do not lie down completely flat on your back.
  • Have your head elevated at least 30 degrees.
  • Do not perform movements such as looking underneath the kitchen sink.
  • Keep your head above the level of your heart.


You may experience lingering disequilibrium for 2-4 days after treatment. If the BPPV was successfully treated, these symptoms should improve. The reoccurrence rate of BPPV in our clinic is about 20% at 6 months and 30% at a year. If you have a return of vertigo or worsening of symptoms call our office.