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  • Benign Paroxysmal Positional Vertigo (or BPPV) is the most common cause of vertigo, a false sensation of spinning.1

    • Benign – it is not life-threatening
    • Paroxysmal – it comes in sudden, brief spells
    • Positional – it gets triggered by certain head positions or movements
    • Vertigo – a false sense of rotational movement


    BPPV is a mechanical problem in the inner ear. It occurs when some of the calcium carbonate crystals (otoconia) that are normally embedded in gel in the utricle become dislodged and migrate into one or more of the 3 fluid-filled semicircular canals, where they are not supposed to be. When enough of these particles accumulate in one of the canals they interfere with the normal fluid movement that these canals use to sense head motion, causing the inner ear to send false signals to the brain.


    Figure 1: Inner ear anatomy. Otoconia migrate from the utricle, most commonly settling in the posterior semicircular canal (shown), or more rarely in the anterior or horizontal semicircular canals. The detached otoconia shift when the head moves, stimulating the cupula to send false signals to the brain that create a sensation of vertigo. © Vestibular Disorders Association. Image adapted by VEDA with permission from T. C. Hain.

    Fluid in the semi-circular canals does not normally react to gravity. However, the crystals do move with gravity, thereby moving the fluid when it normally would be still. When the fluid moves, nerve endings in the canal are excited and send a message to the brain that the head is moving, even though it isn’t. This false information does not match with what the other ear is sensing, with what the eyes are seeing, or with what the muscles and joints are doing, and this mismatched information is perceived by the brain as a spinning sensation, or vertigo, which normally lasts less than one minute. Between vertigo spells some people feel symptom-free, while others feel a mild sense of imbalance or disequilibrium. 

    It is important to know that BPPV will NOT give you constant dizziness that is unaffected by movement or a change in position. It will NOT affect your hearing or produce fainting, headache or neurological symptoms such as numbness, “pins and needles,” trouble speaking or trouble coordinating your movements. If you have any of these additional symptoms, tell your healthcare provider immediately. Other disorders may be initially misdiagnosed as BPPV. By alerting your healthcare provider to symptoms you are experiencing in addition to vertigo they can re-evaluate your condition and consider whether you may have another type of disorder, either instead of or in addition to BPPV.


    BPPV is fairly common, with an estimated incidence of 107 per 100,000 per year2 and a lifetime prevalence of 2.4 percent3. It is thought to be extremely rare in children but can affect adults of any age, especially seniors. The vast majority of cases occur for no apparent reason, with many people describing that they simply went to get out of bed one morning and the room started to spin. However associations have been made with trauma, migraine, inner ear infection or disease, diabetes, osteoporosis, intubation (presumably due to prolonged time lying in bed) and reduced blood flow. There may also be a correlation with one’s preferred sleep side4


    BPPV Figure 2a.

    Figure 2: The right Dix-Hallpike position used to elicit nystagmus for diagnosis. The patient is moved from a seated to a supine position with her head turned 45 degrees to the right and held for 30 seconds.



    1. Bhattacharyya N et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 139(5 Suppl 4):S47-81, 2008.
    2. Froehling DA, Silverstein MD, Mohr DN, et al. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 1991;66:596–601.
    3. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710–5.
    4. Shigeno K, et al. Benign paroxysmal positional vertigo and head position during sleep. J Vestib Res. 2012: Jan 1;22(4):197.
    5. Bhattacharyya N et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 139(5 Suppl 4):S47-81, 2008.
    6. Fife TD, et al. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): Report on the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067-74.
    7. Parnes LS, et al. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003 169(7):681-693.
    8. Nuti D, Nati C, Passali D. Treatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions. Otolaryngol Head Neck Surg 2000;122:440-4.
    9. Fife TD, et al. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): Report on the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067-74.
    Author: Sheelah Woodhouse, BScPT
    Benign Paroxysmal Positional Vertigo (BPPV)

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Dr. Alex Smith

Alex Smith is a clinician-researcher who is at the forefront of efforts to integrate Geriatrics and Palliative Care. Dr. Smith received his medical school training in the UC Berkeley/UCSF Joint Medical Program. He completed a primary care internal medicine residency at Brigham and Women's Hospital (BWH) followed by two fellowships, a one-year clinical fellowship in Palliative Medicine at BWH and Dana Farber Cancer Institute, followed by a two-year General Internal Medicine Fellowship at Beth Israel Deaconess Medical Center, including an MPH from the Harvard School of Public Health. Dr. Smith returned to UCSF in July 2008 as faculty in the Division of Geriatrics.

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