Benign paroxysmal positional vertigo (BPPV) explained

What BPPV is

BPPV is a problem with the balance organs in the inner ear. Deep inside each ear are tiny, fluid-filled canals that sense the movement of your head and help you keep your balance. Normally, small crystals of calcium sit in a separate part of the inner ear. In BPPV, some of these crystals become dislodged and drift into the balance canals, where they do not belong. When you move your head into certain positions, the crystals shift and send confusing signals to the brain, which briefly feels as though the world is spinning. The name explains it well: benign means it is not dangerous, paroxysmal means it comes in sudden short bursts, positional means it is triggered by position, and vertigo means the spinning sensation.

What it feels like

The hallmark of BPPV is short-lived vertigo — a spinning sensation — brought on by a change in head position. Typical triggers include rolling over in bed, lying down or sitting up, tipping the head back to look up, or bending forwards. Each episode usually lasts only seconds to a minute or so, then settles, although the movement that set it off can bring it back. Some people also feel sick, unsteady or lightheaded for a while afterwards. Importantly, BPPV does not cause hearing loss, ringing in the ears, headache, or ongoing dizziness that is present even when you keep still. Between episodes, people are usually well. Recognising this pattern of brief, position-triggered spinning is central to telling BPPV apart from other causes of dizziness.

Why it happens and who gets it

BPPV is caused by those tiny inner-ear crystals coming loose and moving into the balance canals. Often there is no obvious reason why this happens, and it becomes more common with age. Sometimes it follows a knock to the head, a spell in bed with another illness, or an inner-ear infection. It can also come and go, settling on its own and occasionally returning weeks, months or years later. BPPV is very common and, while unpleasant, is not a sign of anything sinister in the brain. It is one of the most frequent causes of dizziness that doctors see, particularly in older adults, where the sudden unsteadiness can also increase the risk of falls, which is one reason it is worth getting diagnosed and treated.

How BPPV is diagnosed and treated

BPPV is usually diagnosed from the typical story and a simple bedside test. In the commonest test, the clinician helps you lie back quickly with your head turned to one side and watches your eyes for a characteristic flicker while you feel the brief vertigo; this confirms the diagnosis and shows which ear is affected. The good news is that BPPV can often be treated on the spot with a specific sequence of head and body movements, such as the Epley manoeuvre, which guides the loose crystals out of the balance canal back to where they cause no trouble. Many people improve after one or two of these treatments. Sometimes a course of gentle exercises to do at home is also recommended. Medicines are generally not the answer for BPPV.

When dizziness needs checking further

BPPV itself is harmless, but dizziness has many causes, and some need urgent attention. It is important to seek help if dizziness is accompanied by warning signs that suggest a problem in the brain or elsewhere, such as a sudden severe headache, weakness or numbness, slurred speech, drooping of the face, double vision, difficulty walking, or dizziness that is constant rather than triggered by position. New hearing loss or ringing in one ear alongside dizziness also needs assessment. Fainting or chest symptoms point to other causes too. If you have brief spinning only on certain head movements and are otherwise well, BPPV is likely, but a clinician should confirm it. Anyone with the stroke-like warning signs above should treat it as an emergency and call 999.