Waking up and rolling over, only to feel the room spin, can be frightening. For many people, this type of brief, intense dizziness is caused by benign paroxysmal positional vertigo, usually shortened to BPPV. It is one of the most common causes of vertigo, particularly in people over 50, but it can happen at any age.
The word "benign" means it is not life threatening, although it can certainly be disruptive. The encouraging news is that BPPV is often very treatable, and physiotherapists trained in vestibular assessment can play a useful role.
What causes BPPV?
Your inner ear contains a balance system made up of fluid-filled canals and small sensory organs. Tiny calcium carbonate crystals, called otoconia, normally sit in one part of this system. In BPPV, some of these crystals become dislodged and drift into one of the semicircular canals.
When you move your head in certain directions, the loose crystals shift and send a false signal to the brain that you are spinning. The posterior canal is most commonly affected, while the horizontal canal is involved less often and needs a different treatment approach. BPPV can occur after a head knock, a viral ear infection or long periods lying down, but often there is no clear cause.
What are the symptoms of BPPV?
BPPV has a fairly distinctive pattern. Common symptoms include:
Short episodes of spinning vertigo, usually lasting less than a minute
Symptoms triggered by specific head movements, such as rolling over in bed, lying down, looking up or bending forward
Nausea, and sometimes vomiting, during or after episodes
A lingering sense of unsteadiness or lightheadedness between episodes
BPPV does not usually cause hearing loss, ringing in the ears, headache or weakness. If you have those symptoms, a different cause needs to be considered.
How is BPPV diagnosed?
BPPV is diagnosed through a careful history and positional tests. The most common is the Dix-Hallpike test, where the head is turned and you are moved from sitting to lying with your head slightly lowered. If this reproduces vertigo along with characteristic eye movements, called nystagmus, it helps identify which ear and which canal are involved.
Other tests, such as the supine roll test, check the horizontal canal. Scans are not usually needed to diagnose BPPV, but your GP may arrange further investigations if symptoms do not fit the typical pattern.
How can a physio help with BPPV?
Physiotherapists with vestibular training can assess and treat BPPV using canalith repositioning manoeuvres. These are a series of guided head and body positions designed to move the loose crystals out of the canal and back to where they cause no symptoms. The Epley manoeuvre is the most well known.
A typical appointment starts with questions about your symptoms, what triggers them and your general health. Positional tests are then used to confirm whether BPPV is likely and which canal is involved. If it is, the matching manoeuvre is performed, which may briefly bring on dizziness while the crystals move. Some people prefer to have someone drive them home afterwards, as they can feel a little off balance for a short time.
Research suggests repositioning manoeuvres are effective for many people with BPPV, and some notice improvement after one or a few sessions. Others may need several treatments, particularly if more than one canal is involved. Our vertigo and vestibular therapy is provided by our physiotherapy team.
If unsteadiness lingers after the vertigo settles, vestibular rehabilitation exercises may help retrain balance and confidence. This can overlap with balance rehabilitation, especially after a head injury.
Can BPPV come back?
Yes, recurrence is fairly common, and some people experience another episode months or years later. The upside is that if it returns with the same pattern, it can usually be assessed and treated again in the same way.
Your physio may show you a home exercise if appropriate, but it is worth having a professional confirm which side and canal are involved first. Doing the wrong manoeuvre may not help and can bring on symptoms. Keeping a note of when episodes happen and which movements trigger them can also be useful information to bring to your appointment.
When is dizziness a medical emergency?
Not all dizziness is BPPV. Call 000 or go to an emergency department straight away if dizziness comes with any of the following, as these may be signs of a stroke or other serious condition:
Facial drooping, arm or leg weakness, or slurred speech
Double vision, loss of vision or trouble swallowing
A sudden, severe headache
Difficulty walking or severe imbalance
Constant vertigo lasting hours or days rather than brief episodes
Sudden hearing loss
See your GP promptly if vertigo follows a significant head injury, or comes with ear pain, discharge or fever.
Who is more likely to get BPPV?
BPPV can happen at any age, but it becomes more common as we get older. It may also be more likely after a knock to the head, after a period of extended bed rest, or in people who have had other inner ear problems. In many cases, though, there is no clear trigger at all.
How can you stay safe while you have BPPV?
Even brief spinning can throw you off balance, and falls are a real concern, particularly for older adults. Until your symptoms settle, these simple steps may help:
- Sit on the edge of the bed for a moment before standing up in the morning.
- Turn your head and roll over slowly, especially in bed.
- Use a night light so you are not getting up in the dark.
- Hold a rail on stairs and take care on ladders, step stools and uneven ground.
- Avoid driving or working at heights while you are having episodes.
If dizziness has knocked your confidence or left you feeling unsteady on your feet, balance and strength work can be part of your recovery. Our mobility, strength and movement therapy page explains how this may help, and you can see the full range of care on our services page.
Frequently asked questions
Will BPPV go away on its own?
BPPV can settle by itself over weeks or months in some people. Many choose treatment because repositioning manoeuvres may shorten the duration and help them get back to normal activities sooner.
Can neck problems cause dizziness?
Some people experience dizziness associated with neck pain or stiffness, sometimes called cervicogenic dizziness. A thorough assessment can help tell this apart from BPPV. You can read more about neck pain and tension.
What should I do after a repositioning treatment?
Your physio will give you advice specific to your situation. Many people are encouraged to move normally afterwards, and some feel mildly off balance for a day or two.
Getting help on the Gold Coast
If brief spinning episodes are affecting your sleep, work or confidence, The Good Joint in Mermaid Beach offers vestibular physiotherapy with no referral needed for most appointments. You can book online or call 07 5651 6594, and our new client information page explains what to expect.
Related reading: How long does whiplash take to recover? and Can a chiropractor help with tension headaches?
