BPPV Explained
You roll over in bed, look up to grab something from a high shelf, or lie back at the hairdresser, and suddenly the room spins. It settles within a minute, then happens again the next time you move your head the same way. This pattern is typical of benign paroxysmal positional vertigo (BPPV), one of the most common causes of vertigo.
This guide explains what BPPV is, why it happens, how it is assessed, and how it is commonly treated.
Not sure it's BPPV? Positional vertigo is usually harmless, but vertigo with severe headache, weakness, numbness, facial droop, slurred speech, double vision, difficulty walking or sudden hearing loss needs emergency care. Call 000. When should dizziness be checked by a doctor?
What does BPPV stand for?
- Benign: it isn't life-threatening, although it can be very unpleasant and disruptive
- Paroxysmal: it comes on suddenly in brief episodes
- Positional: it is triggered by particular head positions or movements
- Vertigo: a spinning or moving sensation
What causes BPPV?
Inside each inner ear are three fluid-filled semicircular canals that detect head rotation, and small organs that sense gravity and straight-line movement. These gravity sensors contain tiny calcium carbonate crystals called otoconia.
In BPPV, some of these crystals become dislodged and drift into one of the semicircular canals. When you move your head, the loose crystals shift within the fluid and send a false "spinning" signal to the brain. The posterior canal is most commonly affected, though the horizontal and anterior canals can be involved.
Why the crystals come loose isn't always clear. BPPV is more common with age, and it can follow a head knock, a period of bed rest or another inner-ear problem. Often, no specific trigger is found.
Common symptoms of BPPV
People with BPPV commonly describe:
- brief spinning vertigo, usually lasting less than a minute, triggered by:
- rolling over or getting in and out of bed
- lying down or sitting up
- looking up or bending forward
- nausea during or after an episode
- feeling unsteady, off-balance or "wobbly" between episodes
BPPV doesn't usually cause hearing loss, ear pain, headache or ongoing spinning while you are still. These symptoms suggest a different cause and should be discussed with your doctor.
How is BPPV assessed?
BPPV is diagnosed from your history and specific positional tests. A doctor or a physiotherapist trained in vestibular assessment can perform them.
Your history
Your clinician will ask what triggers your symptoms, how long episodes last, whether you have hearing changes or headaches, and whether you have any neck or back problems that affect how you can be positioned.
Positional testing
- Dix-Hallpike test: you are moved from sitting to lying with your head turned and slightly extended over the edge of the bed. This tests the posterior canals, the most commonly affected.
- Supine roll test: while you lie on your back, your head is turned to each side to check the horizontal canals.
During these tests the clinician watches your eyes closely. Loose crystals produce a characteristic pattern of involuntary eye movements called nystagmus. The direction and timing of the nystagmus help identify which ear and which canal are affected, which decides the treatment.
The tests can briefly bring on your vertigo. That's expected, and your clinician will support you through it.
Learn more about what happens during a vestibular assessment.
How is BPPV treated?
Repositioning manoeuvres
The main treatment for BPPV is a canalith repositioning manoeuvre: a sequence of guided head and body positions that use gravity to move the loose crystals out of the canal and back to where they no longer cause symptoms.
- The Epley manoeuvre is the best-known and is used for the posterior canal.
- Other manoeuvres, such as the Semont manoeuvre or roll (barbecue) manoeuvres, are used depending on which canal is involved.
Repositioning manoeuvres are well supported by research for posterior-canal BPPV, and many people notice improvement after one or a few treatments. How quickly someone improves varies. It depends on which canal is involved, how long symptoms have been present and individual factors.
After a manoeuvre
Some people feel slightly unsteady or "off" for a day or two afterwards. Your clinician will give you advice about activity, sleeping position and when it is reasonable to drive based on your situation. Follow their individual guidance.
When symptoms don't fully settle
If unsteadiness or movement sensitivity remains after the crystals have been repositioned, vestibular rehabilitation exercises such as balance and habituation training may help your balance system readjust. If symptoms don't fit BPPV or don't respond as expected, your clinician should discuss referral to your GP or a specialist.
Can BPPV come back?
Yes. BPPV can recur, sometimes months or years later, and sometimes in a different canal or the other ear. Recognising the familiar pattern early means it can be reassessed and treated again.
Can I treat BPPV myself?
Online videos show home versions of the Epley manoeuvre. The challenge is that the correct manoeuvre depends on which ear and which canal are affected. Using the wrong one may not help, and some people have neck, back or other conditions that make certain positions unsuitable. A proper assessment first is the safer approach.
Key points
- BPPV is a common cause of brief, position-triggered spinning vertigo.
- It happens when tiny inner-ear crystals (otoconia) move into a semicircular canal.
- It is diagnosed with a history and positional tests such as the Dix-Hallpike and supine roll tests.
- Repositioning manoeuvres like the Epley are the main treatment, matched to the affected canal.
- Vertigo with neurological symptoms or hearing loss isn't typical of BPPV and needs medical assessment.
This article is general information only and is not a substitute for individual medical advice.
References
- healthdirect.gov.au/vertigo (Epley, Brandt-Daroff)
- Bhattacharyya et al., Clinical Practice Guideline: BPPV (Otolaryngol Head Neck Surg, 2017 update)
- Tasmanian Health primary care dizziness guidelines (2024)