Understanding BPPV, a common cause of vertigo
Waking up to find the room spinning when you roll over in bed, feeling a sudden rush of dizziness when you look up at a high shelf, can be frightening. For many people who experience this, the cause is Benign Paroxysmal Positional Vertigo, more commonly known as BPPV. It is one of the most common causes of vertigo; it is treatable and is underdiagnosed.
What is BPPV?
The inner ear contains tiny calcium carbonate crystals, known as otoconia, which help the brain sense gravity and movement. Certain triggers, such as head trauma or local inflammation, may cause these crystals to become dislodged, and the resulting crystalline debris migrates into one of the semicircular canals, the fluid-filled tubes responsible for detecting rotation.
When this happens, head movement can cause the displaced crystal debris to shift, like shaking a Christmas snow model, stimulating the balance cells in ways the brain does not expect, producing a brief but intense sensation of spinning, or rotational vertigo
The episodes are typically short, lasting between five and thirty seconds, and are triggered by specific movements: lying flat, rolling over in bed, sitting up, bending forward, or tilting the head back. Nausea often accompanies an attack, and some people also experience a brief period of imbalance or unsteadiness afterwards.
Which is the commonest type of BPPV?
Whilst there are three semicircular canals, which monitor head movements in any direction, the posterior semicircular canal is almost always affected by BPPV. This is explained by the anatomical orientation of the semi-circular canal openings with respect to gravity. When the subject is in an upright position, the two openings for the superior (anterior) canal point downwards and those for the lateral (horizontal) canal point obliquely downwards. However, one of the openings of the posterior semi-circular canal points downwards, and the other one faces upwards in the opposite direction to gravity. This creates the potential for debris to become trapped in the inferior part of the canal, forming an anatomical sump.
According to Meniere’s and Vestibular UK, BPPV is estimated to affect roughly 50% of all people at some point in their lives, and it becomes progressively more common with age. It is frequently misattributed to anxiety, general dizziness, or inner ear infection, which delays appropriate treatment.
Why women, age and menopause matter
BPPV is more common in women than in men, particularly in the perimenopausal years. A review published in Frontiers in Neurology found that BPPV increases with age, with a female-to-male ratio of between 2:1 and 3.2:1 in adults aged 40 to 60. The research points to oestrogen decline as a significant factor: oestrogen receptors are present in the inner ear, and the sharp drop in oestrogen during menopause is thought to disrupt otoconial metabolism, making the crystals more likely to become dislodged. Osteoporosis, which is also associated with menopause and oestrogen loss, has been independently linked to an increased occurrence and recurrence of BPPV.
For women in their forties, fifties and sixties who are experiencing new or recurring bouts of positional vertigo, this hormonal connection is worth discussing with a specialist, particularly if other menopausal symptoms are present.
Diagnosis and treatment for balance disorders
Diagnosing BPPV requires a specialist assessment. The standard diagnostic test is the Dix-Hallpike manoeuvre, in which the specialist moves the patient’s head through a series of positions while observing the characteristic eye movements, called nystagmus, that BPPV produces. This, alongside a detailed history and a full balance disorders assessment, allows a confident diagnosis to be reached in a single appointment.
Nystagmus, a type of anomalous eye movement triggered by altered vestibular neuronal activity, must be present to be certain of the diagnosis of BPPV. Patients with other types of vestibular disorder can develop a ‘sensitive labyrinth’ (peripheral balance organ). When stimulated by sudden head movement, the patient with a ‘sensitive labyrinth’ may experience transient subjective dizziness and mild nausea, but nystagmus is not observed. This phenomenon can lead to an inappropriate diagnosis of BPPV by the inexperienced clinician.
Treatment for BPPV can provide immediate relief. The Epley manoeuvre is a carefully sequenced series of head positions designed to guide the displaced crystal debris back out of the semicircular canal and into a part of the inner ear where it can no longer cause symptoms. Research indicates that the Epley manoeuvre is effective in around nine out of ten patients, usually after just one treatment. Sometimes preliminary treatment with a vibrator placed over the mastoid bone is required to dislodge the crystalline debris prior to an Epley repositioning manoeuvre.
For patients with recurrent BPPV, further investigation into contributing factors, such as vitamin D levels or bone density, may also be worthwhile.
Assessed and treated under one roof
At The Harley Street ENT Clinic, our specialists assess and treat vertigo and balance disorders with the full range of diagnostic tests and treatments available in a single consultation where possible. If BPPV is confirmed, the Epley manoeuvre can often be performed at the same appointment, meaning you can leave with your symptoms already resolved.
If you are experiencing sudden dizziness triggered by head movements, do not put it down to tiredness or getting older. BPPV is very treatable. Call us on 020 8003 4480 to arrange a consultation with one of our ear specialists.