Benign paroxysmal positional vertigo (BPPV): Causes and treatment

Ever roll over in bed and suddenly feel like your mattress is auditioning for a theme-park ride? If the room spins for
a few seconds (sometimes with bonus nausea), then settles down like nothing happenedwelcome to the oddly dramatic world
of benign paroxysmal positional vertigo (BPPV).

The good news: BPPV is common, usually not dangerous, and often very treatable. The slightly annoying news: it tends to
show up at the worst possible timeslike when you’re trying to look calm in a yoga class or gracefully get out of bed
like a functional adult.

What is BPPV, exactly?

BPPV is a type of vertigo (a spinning sensation) triggered by changes in head positionthink: tipping your head back,
bending over, lying down, or turning over in bed. Episodes are typically brief, often lasting seconds to a minute,
but they can feel longer when your brain is busy filing a complaint with management.

Why it feels so intense (a quick inner-ear tour)

Your inner ear has a balance system that includes semicircular canals (they detect rotational movement)
and a nearby area called the utricle (it helps sense gravity and linear movement). The utricle contains
tiny calcium carbonate crystals called otoconiayou can think of them as microscopic “weights” that help
your balance system do its job.

In BPPV, some otoconia slip out of their usual spot and wander into a semicircular canal where they don’t belong.
When you move your head, those stray crystals move the fluid in the canal in a way that sends confusing signals to your
brain. Your eyes may reflexively “jump” (called nystagmus), and your brain interprets the mixed messages
as spinning.

Causes: why do those “ear crystals” go rogue?

Many cases are idiopathicwhich is medical-speak for “we can’t point to one clear reason.” Still, there
are common patterns and triggers that show up in real life and clinical research.

Common causes and risk factors

• Age-related changes: BPPV becomes more common as people get older.
• Head injury: Even a minor bump can sometimes dislodge otoconia.
• Inner ear inflammation or infections: Conditions that affect the inner ear may increase risk.
• Recent periods of inactivity: Prolonged bed rest or reduced movement can be associated with BPPV in some people.
• Prior BPPV: Recurrence is commonyour inner ear may be a repeat offender.

BPPV most often involves the posterior semicircular canal, but it can also affect the horizontal (lateral)
canal, which can change the best treatment maneuver.

Symptoms: what BPPV typically feels like

BPPV is famous for being positional and brief. The hallmark symptom is vertigo triggered by certain
head movements, often with a short delay after you move, and then a fade-out as the episode resolves.

Common symptoms

• A spinning sensation (vertigo) when lying down, sitting up, rolling over, bending, or looking up
• Nausea (sometimes vomiting)
• Unsteadiness or feeling “off” between episodes
• Abnormal eye movements (nystagmus) observed during testing

Symptoms that are not typical of BPPV

BPPV usually does not cause hearing loss, ringing in the ears (tinnitus), fainting, severe headache,
slurred speech, weakness, numbness, or trouble speaking. If those show up, you should be evaluated promptly because
other causes of dizziness/vertigo can be more serious.

Diagnosis: how clinicians confirm BPPV

A good diagnosis usually starts with a careful history: what triggers the dizziness, how long it lasts, and what other
symptoms come with it. Then the clinician uses positional tests designed to reproduce symptoms and look for nystagmus.

The Dix-Hallpike test (the classic)

The Dix-Hallpike maneuver is commonly used to diagnose posterior canal BPPV. A clinician guides you from
sitting to lying back with your head turned and slightly extended, then watches your eye movements. The pattern of
nystagmus helps confirm BPPV and suggests which ear/canal is involved.

Supine roll test (often used for horizontal canal BPPV)

If symptoms suggest horizontal canal involvement (often more intense spinning with rolling in bed), clinicians may use a
supine roll test to trigger and observe characteristic eye movements.

Do you need imaging (CT/MRI) or lots of lab tests?

Usually not. In straightforward BPPV, the diagnosis is clinical, and the most effective treatment is a repositioning
maneuvernot a scanner. Imaging may be considered if symptoms are atypical, persistent, or accompanied by “red flag”
neurologic signs.

Treatment: getting the crystals back where they belong

The frontline treatment for BPPV is beautifully low-tech: canalith repositioning maneuvers. These are
guided head-and-body movements designed to move the displaced otoconia out of the semicircular canal and back into the
utricle, where they’re less likely to cause trouble.

1) Canalith repositioning maneuvers (the MVP of BPPV care)

The most well-known maneuver is the Epley maneuver, commonly used for posterior canal BPPV. Many people
improve quicklysometimes after one treatment, sometimes after a few. A clinician (or trained physical therapist) can
perform it in the office and may teach a safe home version for appropriate patients.

Other maneuvers may be used depending on the canal involved:

• Semont maneuver: an alternative for posterior canal BPPV
• Brandt-Daroff exercises: habituation-style home exercises that may help some patients, especially when symptoms linger
• “Log roll” / Barbecue roll: commonly used for horizontal canal BPPV
• Gufoni maneuver: another option for certain horizontal canal variants

A practical tip: BPPV treatment is not “one-maneuver-fits-all.” The best maneuver depends on which canal is affected and
what eye-movement pattern shows up during testing. That’s why getting evaluatedespecially for your first episodecan
save you a lot of frustrating trial-and-error.

2) Vestibular rehabilitation (when you need extra support)

If you’re still unsteady after repositioning maneuvers, or if you’ve had recurrent episodes, a clinician may recommend
vestibular rehabilitation therapy (VRT). This is a targeted physical therapy approach that helps your
brain recalibrate balance and reduce dizziness through specific exercises.

3) Medications: helpful sometimes, but not the main fix

Medications that suppress vestibular symptoms (like certain antihistamines or benzodiazepines) may reduce nausea or
motion sensitivity short-term. But they don’t move the crystals and can sometimes slow compensation or make you sleepy,
which is not ideal when you’re already wobbly. In many cases, the fastest route to relief is still the right maneuver.

4) Surgery: extremely rare

Surgery is rarely needed. It may be considered only in stubborn cases that fail repeated, appropriate maneuvers and
significantly impact quality of lifetypically under specialist care.

Self-care and recovery: what to do (and not do) after treatment

After a repositioning maneuver, some people feel immediate relief; others feel “floaty” or mildly off for a day or two.
That can be normal as your balance system settles down.

Practical safety tips

• Move carefully for 24–48 hours if you’re still symptomaticespecially on stairs.
• Avoid risky situations during active vertigo (ladders, driving, operating machinery).
• Hydrate and rest if nausea has limited your intake.
• Fall-proof your space: good lighting at night, clear tripping hazards, use a handrail if needed.

Can you do the Epley maneuver at home?

Some reputable medical centers provide instructions for a home Epley maneuver. But it’s smartest to get a confirmed
diagnosis firstespecially if you have neck/back problems, vascular issues, recent surgery, or symptoms that don’t match
classic BPPV. A clinician can confirm the affected side/canal so you’re not doing a perfectly executed maneuver… for the
wrong ear.

When vertigo is an emergency: don’t “tough it out”

Most BPPV is not dangerous, but dizziness can also be caused by conditions that require urgent care. Seek emergency
evaluation if vertigo is accompanied by:

• Sudden severe headache, neck stiffness, or fever
• Fainting, chest pain, or trouble breathing
• Weakness, numbness, facial droop, trouble speaking, confusion, or severe trouble walking
• Double vision, new vision loss, or severe coordination problems
• New hearing loss or severe, persistent vomiting/dehydration

Recurrence: why BPPV can come back (and what helps)

BPPV has a habit of recurring for some peoplesometimes months or years later. Recurrence doesn’t mean you did anything
“wrong.” It may reflect how your otoconia naturally age or how your inner ear responds to stressors (injury, inflammation,
or other balance-related conditions).

What may reduce recurrence risk

• Getting prompt treatment when symptoms appear (less time wobbling around = less fall risk)
• Following up with vestibular rehab if you remain unsteady
• Discussing bone health and vitamin D status with a clinician if you have recurrent episodes (especially if you’re deficient)
• Staying generally active and practicing balance-safe movement

Frequently asked questions

Is BPPV the same as “regular dizziness”?

Not really. BPPV is a specific, positional type of vertigo caused by misplaced otoconia. Many other conditions can cause
dizziness (dehydration, medication side effects, low blood pressure, anxiety, vestibular neuritis, migraine, and more).
The “triggered by head position and lasts seconds” pattern is a big clue for BPPV.

Can BPPV go away on its own?

Yes, it can resolve spontaneously over weeks to months. But because symptoms can be disruptive (and increase fall risk),
many people prefer treatment that can shorten the misery timeline.

Why do I feel worse during the maneuver?

During a properly performed repositioning maneuver, it’s common to briefly trigger vertigobecause the crystals are
moving. As unpleasant as that is, it can be a sign the maneuver is doing its job.

Real-world experiences: what BPPV feels like (and what helps)

If you ask people to describe BPPV, you’ll hear stories that sound like they accidentally entered a low-budget spaceship
simulator. One common theme: the first episode is often terrifying because it’s so sudden. Someone may roll to the right
to silence an alarm, and in that moment, the room flips like a pancake. They sit up fast (reasonable!), which can make
it feel even worse (unfair!). Then, just as they’re considering writing a farewell message to their group chat, it fades.

Many people notice the “BPPV pattern” in hindsight: it’s triggered by specific positionslooking up to reach a shelf,
bending to tie shoes, lying back at the dentist, turning the head during a workout. Between episodes, they may feel
slightly off-balance, like they’re walking on a dock that’s gently bobbing. That in-between sensation can lead to
second-guessing: “Am I still dizzy, or am I just anxious about getting dizzy?” (Sometimes it’s both. Brains are helpful
like that.)

In clinics, a classic moment happens during the Dix-Hallpike test: the patient says, “Oh wow, that’s itthat’s the exact
spin,” while the clinician watches the telltale eye movement pattern. Weirdly, many people feel relieved in that moment.
Not because the spin is fun (it is not), but because there’s a name for it, it’s common, and it’s treatable. Uncertainty
is heavy; a diagnosis can lighten the load.

After a repositioning maneuver like Epley, experiences vary. Some people walk out feeling dramatically betterlike
someone hit the “stabilize camera” button on their life. Others feel mildly woozy for a day or two, especially with quick
head turns. A common report is that the “violent spins” stop, but mild imbalance lingers briefly. That’s where vestibular
rehab can help: it gives the nervous system structured practice to regain confidence and steadiness.

People who’ve had recurrent BPPV often develop a practical, almost comedic relationship with it. They learn their
“trigger side,” become experts at slow-motion bed rolls, and keep a mental checklist: sleep, hydration, safe movement,
and calling a clinician if symptoms don’t match the usual script. Many describe an emotional arc: fear at first,
frustration during recurrences, and eventually a calm, informed response. The goal isn’t to “power through” vertigo
it’s to treat it efficiently, protect yourself from falls, and get back to normal life as quickly as possible.

If there’s one experience-based takeaway, it’s this: BPPV is miserable, but it’s often fixable with the right maneuver.
If your symptoms are classic, get evaluated, get properly treated, and don’t let a few rebellious ear crystals bully you
out of living your life.

Conclusion

BPPV is one of the most common causes of positional vertigo, typically triggered by head movements and driven by
displaced inner-ear crystals (otoconia). The best part of this not-so-fun condition is that it’s often treatable with
canalith repositioning maneuvers like the Epley maneuversometimes with surprisingly fast relief. If symptoms are
unusual, persistent, or accompanied by neurologic warning signs, seek prompt medical evaluation to rule out more serious
causes.