Benign paroxysmal positional vertigo

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 16 Apr 2025

Last updated: 28 Sep 2021

Benign paroxysmal positional vertigo (BPPV) is a common, often self-limiting condition, but can be chronic and relapsing.

Diagnosis is based on a suggestive history and physical examination with a positive Dix-Hallpike manoeuvre or a positive supine lateral head turn. Other tests are not usually required.

Medication is not an effective treatment option.

Repositioning manoeuvres are highly efficacious in resolving an episode of BPPV.

Surgery is highly effective but is reserved for intractable and severe cases.

Definition

Benign paroxysmal positional vertigo (BPPV) is a peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo elicited by specific head movements. BPPV is one of the most common causes of vertigo. It is often self-limiting, but can become chronic and relapsing with considerable effects on a patient's quality of life. Most cases result from the migration of free-floating endolymph canalith particles (thought to be displaced otoconia from the utricular otolithic membrane) into the posterior (more commonly), horizontal (less commonly), or anterior (rarely) semicircular canals, rendering them sensitive to gravity.[1]

History and exam

Key diagnostic factors

presence of risk factors
specific provoking positions
brief duration of vertigo
episodic vertigo
severe episodes of vertigo
sudden onset of vertigo
nausea, imbalance, and lightheadedness
absence of associated neurological or otological symptoms
normal neurological examination
positive Dix-Hallpike manoeuvre or positive supine lateral head turn
normal otological examination

Full details

Other diagnostic factors

age >50 years
female sex
positional vertigo in absence of nystagmus

Full details

Risk factors

increasing age
female sex
head trauma
vestibular neuronitis
labyrinthitis
migraines
inner ear surgery
Meniere's disease
otitis media
hypertension
hyperlipidaemia
diabetes mellitus
vertebrobasilar insufficiency
giant cell arteritis
osteoporosis
intubation
habitual lateral head-positioning during bed rest (ipsilateral BPPV)

Full details

Diagnostic investigations

1st investigations to order

Dix-Hallpike manoeuvre
supine lateral head turns

Full details

Investigations to consider

audiogram
brain MRI

Full details

Treatment algorithm

ACUTE

initial presentation

ONGOING

multiple repositioning manoeuvres and vestibular rehabilitation exercises ineffective

Contributors

Authors

Lorne S. Parnes, MD, FRCSC

Professor

Departments of Otolaryngology-Head and Neck Surgery and Clinical Neurological Sciences

University of Western Ontario

London

Canada

Disclosures

LSP is an author of a number of references cited in this topic.

Shahin Nabi, MD, FRCSC

Departments of Otolaryngology-Head and Neck Surgery and Clinical Neurological Sciences

University of Western Ontario

London

Canada

Disclosures

SN declares that he has no competing interests.

Peer reviewers

Joel Goebel, MD, FACS

Professor and Vice Chairman

Residency Program Director

Dizziness and Balance Center Director

Otolaryngology-Head and Neck Surgery

Washington University School of Medicine

St. Louis

Disclosures

JG is an author of a number of references cited in this topic.

Stephen P. Cass, MD

Associate Professor

Department of Otolaryngology

University of Colorado

Aurora

Disclosures

SPC is an author of a number of references cited in this topic.

Steven D. Rauch, MD

Associate Professor of Otology and Laryngology

Harvard Medical School

Boston

Disclosures

SDR declares that he has no competing interests.

Malcolm Hilton, BA, BMBCh, FRCS (Eng), FRCS (ORL-HNS)

Consultant Otolaryngologist & Honorary Lecturer

Royal Devon & Exeter NHS Foundation Trust

Exeter

Disclosures

MH is the author of one reference cited in this topic.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014 Dec 8;(12):CD003162.Full text Abstract

Leveque M, Labrousse M, Seidermann L, et al. Surgical therapy in intractable benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2007 May;136(5):693-8. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Meniere's disease
- Vestibular neuronitis
- Labyrinthitis
More Differentials
Guidelines
- ACR appropriateness criteria: dizziness and ataxia
- Clinical practice guideline: benign paroxysmal positional vertigo (update)
More Guidelines
Patient information
Benign paroxysmal positional vertigo
More Patient information
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Benign paroxysmal positional vertigo

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

initial presentation

multiple repositioning manoeuvres and vestibular rehabilitation exercises ineffective

Contributors

Authors

Lorne S. Parnes, MD, FRCSC

Disclosures

Shahin Nabi, MD, FRCSC

Disclosures

Peer reviewers

Joel Goebel, MD, FACS

Disclosures

Stephen P. Cass, MD

Disclosures

Steven D. Rauch, MD

Disclosures

Malcolm Hilton, BA, BMBCh, FRCS (Eng), FRCS (ORL-HNS)

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice