Vertigo and BPPV Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is a disorder caused by problems in the inner ear. The primary symptoms are short episodes of spinning (vertigo), caused by changes in body and head position.

Classification of Vertigo

Vertigo, also called dizziness, accounts for about 6 million clinic visits in the U.S. every year, and 17-42% of these patients eventually are diagnosed with BPPV.

Other forms of vertigo include:

Causes of Vertigo and BPPV

Within the labyrinth of the inner ear lie collections of calcium crystals known as otoconia.  These crystals are normal and function to tell the brain about the direction of gravity or acceleration. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position). When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement and a resultant sensation of vertigo. This more common condition is known as canalithiasis.

In rare cases, the crystals themselves can adhere to the cupula of the semicircular canal rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferent nerves. This condition is termed cupulolithiasis.

BPPV symptoms can be triggered by any action which stimulates the posterior semi-circular canal which may be:

BPPV may be made worse by any number of modifiers which may vary between individuals:

Dizziness and Vertigo

It is difficult to discuss dizziness because it means different things to different people.  There are three main terms in use by physicians which describe what we all refer to as “dizziness

  1. Disequilibrium

Disequilibrium is the sensation of being off balance, much like when getting off a boat, and is sometimes characterized by falls in a specific direction. This condition is not often associated with nausea or vomiting or vertigo.

  1. Pre-syncope

Pre-syncope (literally near fainting) or lightheadedness, like when standing up too quickly. Pre-syncope is often related to low blood pressure.  If loss of consciousness occurs in this situation, it is termed syncope (fainting).

  1. Vertigo

Vertigo is a specific medical term used to describe the sensation of spinning or having the room spin about you. Many people find vertigo very disturbing and often report associated nausea and vomiting.

If the vertigo arises from the inner ear, it is severe and has associated nausea and vomiting. One common cause of otologic vertigo is benign paroxysmal positional vertigo (BPPV). Alternate causes of vertigo originating from the inner ear include Ménière’s disease, superior canal dehiscence syndrome, and labyrinthitis.

If vertigo arises from the balance centers of the brain, it is milder, and has accompanying neurologic deficits, such as slurred speech, double vision or nystagmus. Alternately, brain pathology can cause a sensation of disequilibrium which is an off-balance sensation.

Being able to identify and discuss these different symptoms will help you and your physician narrow down your problem and possibly come up with a treatment for your vertigo

Signs and symptoms of BPPV

Patients do not experience other neurological deficits such as numbness or weakness, and if these symptoms are present, a more serious etiology such as posterior circulation stroke, must be considered.

BPPV Diagnosis

The condition is diagnosed from patient history (feeling of vertigo with sudden changes in positions); and by performing the Dix-Hallpike maneuver which is diagnostic for the condition. The test involves a reorientation of the head to align the posterior canal (at its entrance to the ampulla) with the direction of gravity. This test stimulus is effective in provoking the symptoms in subjects suffering from archetypal BPPV. These symptoms are typically a short lived vertigo, and observed nystagmus. In some patients, the vertigo can persist for years.

The nystagmus associated with BPPV has several important characteristics which differentiate it from other types of nystagmus.

Getting BPPV

People often ask what it was that made them get BPPV.  For many there is never really a satisfactory answer.  However we do know some factors which may pre-dispose a person to getting vertigo due to BPPV.  Any condition which damages the inner ear seems to be associated with BPPV.  This ranges from trauma, to infections to the ever present condition - old age.

To put some specifics on what the etiology or causes of BPPV are:

BPPV is a spectrum of etiologies and presentations which are caused by loose otoconia or inner ear crystals. Most people have similar BPPV symptoms but this is not always the case. It is important that everyone be evaluated by their physician and other causes of dizziness be ruled out.

Chronic BPPV and Duration

After being diagnosed with BPPV many people report mixed feelings.  First - relief at not having a brain tumor or stroke, second - happiness that there is a treatment and third - discomfort with having a chronic disease.

BPPV is indeed a chronic disease.  The otoconia, (normal balance crystals) which cause the symptoms of BPPV when in the wrong place, do not disappear when treated with the Epley Maneuver or with home BPPV treatment, rather the particles are moved.  More than 50% of people will have BPPV more than once and many will have it on a regular basis and some will even have it daily, even if treated properly.

The key to successful treatment of BPPV is to understand how to identify it and how to properly treat it.  BPPV is characterized by sudden spinning, which is short lived and comes on only in certain positions.

Following treatment most people obtain resolution of symptoms immediately.  Even in the worst of cases some duration of symptom free period can be achieved.  Many people report recurrent symptoms within weeks or months of the original attack.

Patients with BPPV on one side often are at risk of having it on the second side. There is no know family predeliction to BPPV.  Rates of BPPV also increase dramatically with age to more than 1 in 10 over the age of 60.

Vertigo Treatment Options

Two treatments have been found effective for relieving symptoms of posterior canal BPPV: the canalith repositioning procedure (CRP) or Epley maneuver, and the liberatory or Semont maneuver. The CRP employs gravity to move the calcium build-up that causes the condition. The particle repositioning maneuver can be performed during a clinic visit by health professionals or taught to patients to practice at home. In the Semont maneuver, patients themselves are able to achieve canalith repositioning. Only limited data are available comparing the two treatments, and it is not known which is more effective.

The Epley maneuver (particle repositioning) does not address the actual presence of the particles (otoconia), rather it changes their location. The maneuver moves these particles from areas in the inner ear which cause symptoms, such as vertigo, and repositions them into areas where they do not cause these problems.

Medical treatment with anti-vertigo medications may be helpful in the acute setting for a severe exacerbation of BPPV. These primarily include drugs of the anti-histamine and anti-cholinergic class, such as scopolamine and meclizine respectively. These offer symptomatic treatment, and do not affect the disease process or resolution rate. These medications are often used in conjunction with particle repositioning maneuver, such as the Epley maneuver, for severe cases of BPPV.

Surgical treatments, such as a semi-circular canal occlusion, do exist for BPPV but carry the same risk as any neurosurgical procedure. Surgery is reserved for severe and persistent cases which fail particle repositioning and medical therapy.

Devices such as a head over heels "rotational chair" are available at some tertiary care centers A home devices, called DizzyFIX, is the preferred and soon to be the most widely used treatment of BPPV and vertigo.

Preferred BPPV treatment: DizzyFIX

The DizzyFIX helps you treat the most common cause of vertigo (spinning dizziness) called BPPV (Benign Paroxysmal Positional Vertigo). In just a few minutes, this device guides you through a proven treatment for BPPV. Just follow the particle in the device to treat yourself at home.

The general objective of the DizzyFIX device is to visually guide the user though the particle repositioning maneuver (Epley maneuver) and achieve successful treatment of BPPV.

The device attaches to any common baseball hat. The device consists of a special tube filled with fluid. The device also contains a particle representing the disease causing otoconia found in the inner ear. The shape of the tube and the motion of the particle provide feedback as to the performance of the particle repositioning maneuver. Simply put, guide the particle through the device and you will have treated your BPPV.

The device enables people to diagnose BPPV, determine the affected side and treat BPPV with similar success as an Otolaryngologist.

The device enables the user to repeat the maneuver as often as required. BPPV may be a chronic condition and up to 50% of people will experience relapse in their lifetime. The DizzyFIX enables people to treat recurrent episodes quickly and effectively.

The DizzyFIX is a patented medical device developed by top ENT physicians and is the only home treatment cleared by the FDA. It has helped thousands and thousands of patients worldwide treat their BPPV with great results.

The DizzyFIX is available for sale in all countries; please click on the following link to order yours today. (Sales Link)

If you are having trouble filling out the sales cart information, please email us at info@clearwaterclinical.com with your name, shipping address and payment information and we will do our best to process your order.

Failure to treat BPPV

I was recently asked: “Has any BPPV patient managed to make their condition worse with a bungled treatment?”

The answer is not particularly straight forward.  Any treatment of BPPV has the potential to convert to something called Horizontal canal BPPV. The most common type of BPPV is Posterior canal BPPV. 

The estimated rate of this complication of treatment of BPPV is about 5%. You run this risk every time you roll over in bed but in particular during a repositioning maneuver. The good news is that horizontal BPPV, while more intense (if you can believe that) it is often short lived and goes away by itself in nearly all cases.

Home treatment of BPPV has no higher risk of this conversion than office maneuvers. The only benefit of the in office treatment is that there is someone there to comfort you.  I also suggest that you never do the maneuver alone even if you are doing it at home. You just never know if you need help if you vomit or feel nauseous.

Treating BPPV Alone or as an Elderly

Someone recently asked me about their elderly mother doing maneuvers for the home treatment of BPPV.  Since she is elderly she apparently had difficulty moving her head back far enough to complete the standard maneuver.    

The good news about home treatment is that the Epley Maneuver can be conducted at home with some help.  This is much more effective than previous maneuvers such as the Brant Daroff exercises.  The hope is that fewer maneuvers need be conducted to successfully treat the condition. 

However, some people should not perform the maneuver.  This includes, amongst others, people with neck injury, limitation of their neck range of motion, a history of stroke/TIA due to vertebro-basilar insufficiency and other health conditions as advised by their doctor.

Certainly home maneuvers are effective but they should not be conducted alone or by people who have difficulty or other medical conditions which put them at risk. Home maneuvers should always be conducted on the floor to prevent falls and in the presence of another person for assistance if needed.  When in doubt see your doctor.

Nystagmus (BPPV eye movements Diagnosis)

One of the key findings in BPPV is the presence of nystagmus.  This is the medical term for the involuntary eye movement which occurs when the body changes position.  It is characterized by alternating smooth pursuit eye movements  in one direction and saccadic (quick catch up) movements in the other direction.  This is a useful phenomonon as it allows people to keep things in focus even moving and turning your head, without it things would be fuzzy when you nod your head.   Nystagmus itself is normal, however there are pathologic forms of nystagmus.

In BPPV there is a phenomenon known as positional nystagmus.  When a person with BPPV is in a position which causes them dizziness their eyes exhibit a characteristic motion, called nystagmus. What happens is the inner ear perceives that body is moving (this is the vertigo associated with BPPV) and tells the eyes to move to keep up. The only problem is that the body is not moving, and having your eyes move involuntarily while you are still can be quite disconcerting.

You can see a video of Nystagmus related to BPPV on Youtube.

The maneuver in the video is called “Dix-Hallpike Maneuver” and it elicits the symptoms of BPPV and, more specifically, the nystagmus.  There are many types of nystagmus but there are a few qualities of which make the diagnosis of BPPV easier.

Nystagmus associated with BPPV has to have the below characteristics:

  1. Positional in onset (only in a head hanging position will it come on)
  2. Short lived (lasts only a few seconds to minutes)
  3. Geotropic - the top of the eye beats (fast phase) toward the side on which your head is hanging
  4. Rotatory and small upbeat component - the eye rotates or twists, as above, and has a slight fast phase up motion
  5. Fatigable - repeating the maneuver again and again will stop it from happening temporarily
  6. Latent onset - there is a slight lag phase of a few seconds before the nystagmus starts when in the head hanging position.

So why do you get nystagmus with BPPV?  Well that can be the subject of another post.

Traveling, Vacationing, and Dizziness

As we have talked about there are various kinds of “Dizziness”. Sometimes people confuse positional vertigo with motion sickness, because they both happen when in motion.

BPPV is characterized by spinning vertigo when changing into certain positions.  These are typically rolling over in bed, looking up and to the side, or looking under something.  Often it happens on a specific side, either left or right, although some unlucky people have BPPV on both sides.  Many people who have BPPV are afraid to travel in case an attack comes on while away from their own physician.  Devices for the treatment of BPPV are available to take with you when away from home.

Motion sickness is a sensation of “Disequilibrium” or being off balance, or feeling like you are moving when you are not.  It is caused by a disjunction between what you see and what you feel, or between what you feel and what your ear is telling you.  A good example of this is when the car beside you at a traffic light rolls backward and it makes you feel like you are rolling into the intersection (your eyes tell you that you are moving but your body and balance organ say you are still).  Not only is this a bit anxiety provoking but it often causes an uncomfortable sickness feeling of disequilibrium.  Another good example is the familiar sensation of reading in a moving car.  Your eyes tell you that you are sitting still, since you are looking at a book, but your ear and body tell you that you are moving.  It is this disjunction that is the culprit in motion sickness.

There is also an under-diagnosed but interesting phenomenon called “Mal de Debarquement” syndrome.  Everyone has heard of sea-sickness (a type of motion sickness) but this happens when you get off the boat.  Typically the individual has not had sea-sickness and is the envy of everyone else until they step back onto dry land. Then they still feel like they are on a boat.  In some cases this is temporary but in others it is permanent.  These people may be seen swaying down the streets as if on board a boat in rough seas.  It is a difficult and very frustrating problem for which there is currently no cure.

In general, traveling with vertigo can be scary.  Tips on traveling can be found at http://jetseventravel.com.  In order to overcome vertigo and get back to living your life, learn as much as you can about your own condition and travel with adequate preparation.  For example, if you get motion sick bring anti-nauseant medication (Gravol/Antivert/Dramamine), if you have Menieres disease, Serc can be useful, and if you have BPPV learn the treatment maneuver or take a self treatment device with you.

Post Epley maneuver precautions

Following a treatment maneuver for BPPV many practitioners recommend staying upright for 48 hours.  This recommendation makes some empiric sense.  The idea behind it is to allow the particles, disturbed like snow in a snow globe, to settle before exposing the opening of the posterior canal by lying down.

However, these precautions were never proven.  In fact, a number of researchers have demonstrated that restrictions do not interfere in the results of the Epley canalith repositioning maneuver. We think that this is because the disturbed particles, like snow flakes, don’t cause problems until they form clumps.  Unfortunately, there is no way to keep the flakes from finding there way back into the posterior canal everytime you “shake the snow globe” by lying down.  Eventually clumps will form again.  This is why BPPV is recurrent.

Many people who do try to complete the post maneuver precautions find that they loose two nights of sleep and get a sore neck. I am not sure it is worth it when there is no evidence for it and plenty against.  Below are three of the published articles on how and why the post maneuver precuations are of limited value.

Epley Maneuver

People often ask, “I have tried the Epley Maneuver, it didn’t work, should I keep trying?”

In general terms, it may take several attempts to fully treat BPPV and most people can expect to have some recurrences.  We suggest that you need only perform the maneuver when you have an attack.  If you are not having symptoms then you don’t need to to do the maneuver although it may prevent recurrences.  It is always important to seek the advice of your own doctor to obtain a diagnosis and to monitor your condition.

With that said here are several important questions to ask yourself about failed BPPV treatment.

  1. Do you have BPPV?
    1. To achieve success with the Epley Maneuver or home treatment for BPPV you must be sure you have a correct diagnosis. These maneuvers do not work if you do not have BPPV.  There are many other types of dizziness, although BPPV is the most common.
    2. Posterior BPPV?
      1. There are actually a number of sub-types of BPPV.  Posterior canal BPPV (P-BPPV) is by far the most common.  The Epley maneuver treats P-BPPV but not the others.
  2. Did you do the maneuver correctly?
    1. Although the treatment maneuvers for BPPV are very effective it is not yet clear how incorrectly you can perform them and still have success.  The major reason for home treatment failure is an incorrectly performed maneuver . Home BPPV treatment devices are designed to minimized this problem.  Careful attention to detail in the maneuver as well as ensuring the correct angles, side and duration will improve success.  The most common mistake,..not putting you head back far enough (it can be too far though).
  3. Do you have bilateral BPPV?
    1. A small percentage of people will have BPPV on both sides and so after successful treatment on one side will still have symptoms.  This can be confusing.  We recommend that people treat one side daily for one week then switch to the other side.
  4. Do you have recurrent BPPV?
    1. BPPV treatment does not cure the problem it only removes the stimulus temporarily so as many as 60% of people will have symptoms more than once.   Some people have highly recurrent BPPV so after they successfully treat one episode it can come back in a matter of days and make them think they failed in their maneuver.  Daily maneuvers may control these problems.  In rare cases of very symptomatic and resistant BPPV surgery can be performed to block of the balance canal which causes BPPV.
  5. Are you ever going to respond?
    1. Do you have something else as well?
      1. BPPV can be found along with any other disease which causes inner ear damage.  Conditions like Menieres, head trauma, or inner ear infections may causes BPPV.  As such it can be confusing as to which condition is causing the vertigo.  Generally these symptoms can be sorted out by a skilled ear doctor.  You might need help with this one.
    2. Do you have resistant BPPV?
      1. About 5% of people have BPPV which is resistant to maneuvers.  This may be because the disease causing crystals are too large to come out of the posterior canal or that they are stuck to the inner ear somewhere.   Regardless the Epley maneuver does not work for these people.  Again in certain circumstances surgery may be indicated.

Epley Maneuver Failure

Although most people with BPPV can be treated with the Epley maneuver or a home treatment device.  About 5-12% of people cannot be treated.  There are several reasons which should be carefully considered.

1) You do not have BPPV.  There are many kinds of vertigo and only BPPV will respond to the Epley maneuver.  You should always get a proper diagnosis from a physician qualified to diagnose BPPV.  Several serious conditions can cause vertigo as part of their symptom complex and these other conditions should be ruled out.

2) You have BPPV but are doing the maneuver incorrectly.    This is actually the most common reason for BPPV treatment failure in people with BPPV.  This may be because you are treating the wrong side or may be because you are performing the maneuver too quickly, with the wrong angles or in the wrong order.  The maneuver is only effective when performed totally correctly.  A BPPV treatment device to assist in the correct performance of the maneuver is available and will visually guide a person through the maneuver.

3) You may have a resistant form of BPPV.  This may be due to the fact that the otoconia, or ear crystals, get stuck in the balance canal or that they get glued to the end of the canal. It is not clear which is true but it seems that some people don’t respond whatever they do.

4) You may have BPPV in both ears.  Due to the nature of BPPV if you have it in one ear it is certainly possible to get it in both ears.  Typically this will present with symptoms on both sides.  A physician can tell you if this is the case.  The Epley maneuver will still work but you will have to do it on both sides.  People often ask if doing one side and then the other will reverse the benefit of the first maneuver. It is not clear that this is true however, we always tell people to treat one side one week then the other side the next week.

With these issues in mind it doesn’t hurt to perform an Epley maneuver in a repeated fashion, it might help but this cannot be guaranteed.    The only caution is that if you have symptoms which do not seem related to BPPV such as weakness or confusion you should seek medical attention.

Additional support for Vertigo

Vertigo and dizziness are very distressing problems.  Some say that nausea is worse than pain.  At least pain makes some physiologic sense.

Vestibular diseases are problematic in that they are so poorly understood. Many patients  end up vague diagnosis such as recurrent vestibulopathy.  Medical science has just not reached a point where we can diagnose every kind of problem.  Further, even those conditions which we can diagnose may not have effective treatments.  Tinnitus is a good example of a difficult to treat condition.  Sure we can tell you what it is, but get used to it, because many times we don’t know how to effectively treat it.  Mind you that is not for a lack of trying.  Some conditions like BPPV are quite easy to treat if you get the right treatment.  However, there are many other causes of vertigo which may not be so easy to treat.

Even if doctors can’t give you a good diagnosis for your condition or an effective treatment there is still hope.  The hope that despite your problem you can overcome it by understanding it and developing coping skills.

There are a number of resources on line which you might find useful in understanding the diseases of the vestibular system

Timothy C. Hain has a great website:

http://www.tchain.com/otoneurology/default.htm or http://www.dizziness-and-balance.com/index.html

Also

http://www.vestibular.org/vestibular-disorders/specific-disorders/bppv.php

There are also a number of very good “on line” support groups for people with similar problems who may be able to offer advice and support  www.thedizzylounge.com or www.dizzytimes.com

Don’t despair - there are new treatments on the horizon every day.

Famous sufferers

Did you know that there are many people suffering from vertigo and you are not alone?

Vertigo Timeline & History

1921 - Benign paroxysmal positioning vertigo (BPPV; also known as positional vertigo) was initially defined by Barany in 1921. The term itself was coined by Dix and Hallpike

1962 - The clinical pathology substrate corresponding to BPPV was proposed by Schuknecht 16 in 1962, which described the presence of crystals coming from utriculus macula, which are released and then adhere to the top of posterior semicircular canal (cupololithiasis)

1974 - Richard R Gacek 7 proposed the first surgical solution in 1974. After several animal experimentations, he began to perform transsection of the posterior ampullary nerve (singular neurectomy);
1974 - In 1974, BPPV was wrongly and illogically attributed to cupulolithiasis — debris adherent to the cupula of the posterior semicircular canal.

1979 - In 1979, SF Hall, RRF Ruby, and JA McClure, from the Department of Otolaryngology at the University of Western Ontario, reconsidered the possibility that BPPV could result from the action of loose material on the cupula of the posterior semicircular canal.

1980 - In 1980, Epley published his theories regarding canalithiasis. 1 He thought that the symptoms of BPPV were much more consistent with free-moving densities (canaliths) in the posterior SCC rather than fixed densities attached to the cupula.

1985 - Lateral semicircular canal benign paroxysmal positional vertigo (LSC-BPPV) was first described by Cipparrone et al 1 and McClure 2 in 1985, characterized by nystagmus provoked by supine bilateral head turns and beating toward the undermost ear.

1988 - Semont et al. reported the results of the 'liberatory maneuver' for the treatment of BPPV with 84% of cure following a single treatment. The authors instructed patients to sleep in the sitting position for two nights, then on the normal side for a further five nights and to use a neck collar for 1 week.

1995 - During the past few years, doctors have found a new treatment for BPPV increasingly successful. Called the Canalith Repositioning Procedures

2005 – Development and testing of the DizzyFIX begins with Drs. Bromwich, Parnes and University of Western Ontario

2006 – Clinical trials of DizzyFIX
2007 – DizzyFIX obtains FDA clearance
2008 – DizzyFIX is produced and shipped worldwide
2009 – DizzyFIX becomes recognized treatment by ENTs for BPPV

DizzyFIX Testimonials

“A single treatment using DizzyFIX curned my distressing vertigo” - J.M. Ontario, Canada
“The dizzyfix has given my freedom back. I am no longer afraid to travel” - T.S. British Columbia, Canada