benign paroxysmal positional nystagmus

Last edited 11/2020 and last reviewed 07/2023

Benign paroxysmal positional vertigo (BPPV) is a disorder characterized by brief recurrent attacks of vertigo provoked by certain changes in head position with respect to gravity (1).

• it is one of the most common causes of vertigo
• also it is the number one vestibular disorder accounting for a 20-30% of referrals to vertigo clinics (2)
• the most common provocative movements are:
  • rolling over in bed
  • bending over
  • looking upward (3)

Involvement of all three semi circular canals can be seen in this disease with the posterior (60-90%) and horizontal (5-30%) canals being the most commonly affected ones (2,4). However the prevalence of horizontal canal BPPV is more than what was previously thought (4).

Because benign positional vertigo is treatable it is an important diagnosis to make.

Diagnostic criteria (5):

A. At least five attacks fulfilling criteria B and C

B. Vertigo* occurring without warning, maximal at onset and resolving spontaneously after minutes to hours without loss of consciousness

C. At least one of the following five associated symptoms or signs:

1. nystagmus
2. ataxia
3. vomiting
4. pallor
5. fearfulness

D. Normal neurological examination and audiometric and vestibular functions between attacks
E. Not attributed to another disorder **

* Young children with vertigo may not be able to describe vertiginous symptoms. Parental observation of episodic periods of unsteadiness may be interpreted as vertigo in young children.
** In particular, posterior fossa tumours, seizures and vestibular disorders have been excluded

Reference:

• (1) Fife TD et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70(22):2067-74
• (2) Bronstein A. Benign Paroxysmal Positional Vertigo (BPPV):Diagnosis and Physical Treatment. ACNR 2005;5(3)
• (3) Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999;341:1590
• (4) Lee SH, Kim JS. Benign paroxysmal positional vertigo. J Clin Neurol. 2010;6(2):51-63
• (5) Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia 2018; 38: 1-211