Benign positional paroxysmal vertigo (BPPV)

Aetiology

BPPV is thought to be caused by crystals forming in the inner ear. It is the movement of these crystals with head movement that is thought to cause the vertigo. The crystals most commonly occur in the posterior semicircular canal. There is an association with head injury but often it is idiopathic. It can occur at the same time as other vestibular causes of vertigo.

Epidemiology

BPPV is extremely rare in children and the rate increases with age with a peak age of around 60.

Clinical Presentation

Typically patients report rotatory vertigo lasting up to a minute triggered by certain head movements such as looking to one side. A good question to ask is if they ever get vertigo in bed on turning to one side as it is rare for any other conditions to cause this symptom. BPPV should not cause balance problems between episodes.

Who to refer, who not to refer, how to refer

If symptoms do not respond within 2 weeks of completing initial treatment with the Epley manoeuvre or Brandt Daroff exercises then refer to Physiotherapy.

If there is associated unilateral ear symptoms such as hearing loss or tinnitus then refer to ENT Surgery as routine via SCI Gateway.

Referral can be by email or SCI Gateway.

If by email, GPs should send BPPV Physiotherapy referrals to the following mailboxes:

PhysiotherapyLTC-BGH@borders.scot.nhs.uk for patients in Central locality

PhysiotherapyLTC-HawickHospital@borders.scot.nhs.uk for Teviotdale

PhysiotherapyLTC-HaylodgeHospital@borders.scot.nhs.uk for Tweeddale

Bor.berwickshireahpreferrals@borders.scot.nhs.uk for Berwickshire

CheviotCHT.Referrals@borders.scot.nhs.uk for Roxburghshire

Primary care management

Diagnosis

The Dix- Hallpike test as demonstrated in this BMJ youtube video is easy to perform in the clinic room and is diagnostic for BPPV if positive. It is important to check that the patient does not have any neck problems that could be aggravated by carrying out this test. Classically it produces rotatory geotropic nystagmus. This means that the 12 o’ clock position of the iris rotates towards the floor. As the iris is often symmetrical it can sometimes be easier to look at any blood vessels on the surrounding sclera to detect the rotation. The patient will experience vertigo replicating their symptoms during the nystagmus. The nystagmus is normally delayed by a number of seconds and if the Hallpike test is repeated a number of times in a row the nystagmus and vertigo become less. For this reason if a patient has had recent vertigo a negative test does not mean that they do not have BPPV.

It is sensible to do the Hallpike manoeuvre on the contra-lateral side to the one you expect to be positive from the history first. Most patients recover well from the procedure within a few minutes in the waiting room but sometimes it can make a patient feel unsteady for a number of hours so patients who are planning to drive home should be warned. If a patient is having a prolonged episode of vertigo from hours to days this is not in keeping with BPPV. Carrying out the Dix-Hallpike test during one of these episodes will make their vertigo and nystagmus worse but this does not mean that they have BPPV.

Treatment

If the Hallpike test is positive the Epley manoeuvre as demonstrated in this BMJ youtube video should be carried out. It is not always possible to see the rotatory nystagmus and if a patient feels vertiginous with the Hallpike test but you did not see nystagmus it is still reasonable to carry out the Epley manoeuvre. Patients can also be given Brandt-Daroff exercises to do at home if you are unable to perform the Epley manoeuvre or if the Hallpike test was negative but you still strongly suspect BPPV.

Resources and links

Brandt Daroff Exercises - Brandt Daroff exercises.pdf

Local service details

ENT@borders.scot.nhs.uk

Last reviewed: 18/09/2025

Next review date: 18/09/2028

Author(s): Esmond Carr.

Author email(s): Esmond.carr@borders.scot.nhs.uk.