Benign paroxysmal positional vertigo (BPPV) is a very common cause of dizziness. Patients have brief, violent spells of whirling dizziness which are brought on by a sudden movement of the head.

Although the vertigo may be severe and often frightening, BPPV is a benign condition that can be cured in most cases.

The symptoms of BPPV include dizziness or vertigo, imbalance, and nausea. These symptoms are almost always brought on by a change in the position of the head or body—such as rolling over in bed or getting out of bed, bending down to tie one's shoe, or tipping the head back to look up (for this reason BPPV is sometimes called "top shelf" vertigo).

An intermittent pattern is the usual situation. BPPV may be present for a few weeks, then stop, then come back again.

What Causes BPPV

BPPV is caused by small particles which float freely within the fluids of the inner ear. These particles are tiny crystals of calcium carbonate. They are derived from structures in the ear called "otoliths," and they are normally attached to the membrane of the inner ear. When these calcium crystals break free, they can drift into one of the balance canals and cause a spell of vertigo.

Small calcium crystals drift into one of the balance canals to cause vertigo.

In most cases, BPPV occurs for no known reason, and is called "idiopathic." In people under the age of 50, BPPV is commonly caused by head injury. In older people, it is often caused by degeneration of the balance system of the inner ear.

Office Treatment of BPPV

The particle repositioning maneuver is a very effective treatment for BPPV that can be performed in Dr. Smouha's office. This procedure has a cure rate of about 80%, with most patients being cured after one session.

The particle repositioning maneuver (also called the Epley maneuver, after its inventor) involves sequential movement of the head into four positions.

The maneuver is intended to move calcium crystals out of the sensitive back part of the ear (posterior canal) to a less sensitive location. The maneuver takes about 15 minutes to accomplish.

The recurrence rate for BPPV after these maneuvers is about 5%, and in some instances a second treatment may be necessary.

Instructions for Patients After Office Treatments

After treatment, you should follow the instructions below, which are aimed at reducing the chance that crystals might fall back into the sensitive part of the ear:

n Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or brief bursts of vertigo as particles re-position themselves immediately after the maneuver. Don't drive home yourself; have someone else drive you.
n Sleep in a semi-sitting position for the next two days. This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch. During the day, try to keep your head vertical. No exercise which requires head movement.
n Two days after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can't fall or hurt yourself. Let your Dr. Smouha know how you did.

If the Particle Repositioning Maneuvers Don't Work

These maneuvers don't always work (in about 20% of cases), and if they don't, then you may be told to proceed with the Brandt-Daroff exercises. They are more arduous, but can be done at home. To do them, follow these instructions:

n Sit on the edge of the bed;
n Lie down quickly to the side that causes the vertigo, so that your ear is resting on the pillow;
n Wait for the vertigo to pass (usually half a minute);
n Sit up quickly, wait for the vertigo to pass, then lie down quickly to the other side;
n Repeat this five times.

The Brandt-Daroff exercises are to be done twice a day, morning and bedtime.