BPPV is the most common cause of vertigo among adults, and is most common in people over the age of 60. Risk factors for recurrent BPPV include osteoporosis, hypertension, migraine, and head trauma. It is a common occurrence after vestibular neuritis. It is rare in children.
BPPV results from displaced otolith crystals from the utricle of the inner ear that wander into the semicircular canals, causing bursts of vertigo when the head in moved in the direction of the affected canal. The vertigo is typically short-lived, lasting less than a minute, and can be accompanied by nausea but rarely vomiting.
The posterior canal is affected almost 80% of the time. Since the posterior canal is responsible for detecting movements that tilt the head backwards or forwards, posterior canal BPPV results in vertigo when a person engages in activities that cause the head to move in this plane. Lying down and getting out of bed are the most typical triggers for vertigo in posterior canal BPPV – patients often note that the attacks of vertigo are most severe when getting out of bed in the morning. At times turning in bed can provoke vertigo as well. Other activities that trigger vertigo when the posterior canal is involved include lying down in a dentist’s or hair stylist’s chair, looking upwards, and bending over.
BPPV is one of the most rewarding conditions to diagnose and treat. It can be quickly diagnosed at the bedside, and the maneuvers used to correct it are highly effective, and safe.
The diagnosis of posterior canal BPPV is straightforward. The Dix-Hallpike maneuver is used to determine if posterior canal BPPV is present, and if so, which side it is on (left or right).
First, find a bed where you can comfortably and safely lie back down with your head hanging off the edge. It is best to have a person there to help you, for safety purposes, and have a bucket handy just in case you need to vomit.
You will start off by performing the Dix-Hallpike maneuver for the right posterior canal. This is how to perform the Dix-Hallpike maneuver for the right side:
Note that the head is turned 45 degrees to the right, and the lie back down so that your head is leaning 30 degrees below horizontal off the edge of the bed. Allow your head to remain in that position for 30 seconds.
If you get a burst of vertigo with your head in this position, that means you have right posterior canal BPPV.
If you do not get any vertigo in that position even after waiting for 30 seconds, that means you most likely do not have right posterior canal BPPV. Sit back up, and perform the Dix-Hallpike maneuver for the left side.
The steps for the left side are identical to those for the right side, except that the head must be turned 45 degrees to the left before you lie back down to allow your head to hang 30 degrees below horizontal off the edge of the bed. Wait in this position for 30 seconds.
If you get a burst of vertigo with your head in this position, that means you have left posterior canal BPPV.
Remember: triggering a burst of vertigo during the Dix-Hallpike maneuver is unpleasant but confirms that you are doing it right!
Treatment – the Epley maneuver
Once you have determined the affected side (either right or left posterior canal), you can perform the Epley maneuver to cure it. The Epley maneuver is a series of head rotations that will basically roll the otolith crystals out of the affected canal. This takes less than 5 minutes.
This is how you can perform the Epley maneuver for RIGHT posterior canal BPPV:
If you determined that you have LEFT posterior canal BPPV, this is how you should perform the Epley maneuver:
Repeat the Dix-Hallpike maneuver to the affected side to confirm that the Epley maneuver was successful. If you still get vertigo in that position, repeat the Epley maneuver.
Remember that you may get a burst of vertigo as you sit up from after the final step of the Epley maneuver. This confirms that the otolith is exiting the posterior semicircular canal. Take precautions to ensure you do not fall off the bed when you sit up, or have someone close by to support you
For 24 hours after performing a successful Epley maneuver:
- Do NOT bend over (head below horizontal)
- Do NOT tilt your head too far backwards
- Kneel or squat down if you have to tie your shoes or pick something off the floor
- Do not go to the dentist or hair stylist
- Do not swim free style (or crawl style)
- If you need to administer eye drops in, you can pull your lower eyelid down and place the eye drops on the inside of the lower eyelid
- To shave, protrude your chin forwards to access the area between your chin and neck
- Sleep in a recliner or use a few pillows at a 45 degree angle
The Half-Summersault Maneuver
If you have neck stiffness or pain, or any condition that makes it difficult for you to hang your head off the edge of the bed backwards, another useful maneuver to treat posterior canal BPPV is the half-summersault maneuver.
This is how you can perform it at home:
After successful treatment with this maneuver, you will observe the same post-maneuver care as described for the Epley maneuver.