Benign Paroxysmal Positional Vertigo (BPPV)

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What is BPPV?

BPPV is a mechanical disorder of the vestibular system characterized by repeated episodes of positional vertigo, caused by displaced otoconia (tiny calcium carbonate crystals) from the utricle that migrate into one of the semicircular canals (posterior, horizontal or anterior).

The canalithiasis theory of BPPV suggests that otoconia, become dislodged and float freely within a semicircular canal. When the head changes position, these free-floating particles move, creating abnormal endolymph flow that deflects the cupula and causes brief, position-triggered vertigo/dizziness (< 60 sec).

The cupulolithiasis theory proposes that dislodged otoconia become attached to the cupula of a semicircular canal. This added weight makes the cupula abnormally sensitive to gravity, leading to persistent stimulation of the vestibular system and prolonged positional vertigo/dizziness (> 60 sec).

The condition is benign but can significantly impair balance and quality of life if untreated.

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History

  • 1921 – BPPV first described by Robert Bárány; attributed to utricular dysfunction.
  • 1960s – Harold Schuknecht proposes the cupulolithiasis theory (otoconia adhere to the cupula).
  • 1969 – Cupulolithiasis formally published as the leading explanation for BPPV.
  • 1970s – Infrared video goggles begin to be used in research and early clinical vestibular testing.
  • 1979 – Hall, Ruby, and McClure introduce the canalithiasis theory (free-floating otoconia).
  • Early 1980s – Dr. John Epley develops a particle repositioning maneuver (unpublished at the time).
  • 1985 – Geotropic horizontal canal BPPV identified and linked to canalithiasis.
  • 1992 – Epley publishes the canalith repositioning maneuver. Parnes & McClure provide surgical proof of moving otoconia in the canal.
  • Mid–1990s – Epley introduces new concepts: canalith jam, cupular impingement, and BPPV variants.
  • 2000s–2020s – Clinical practice guidelines for the treatment of BPPV were introduced in 2008.  Studies and imaging challenge cupulolithiasis theory.  First 3D simulation studies were published.

Etiology

BPPV is most commonly idiopathic, but can also result from head trauma, vestibular neuritis, Meniere’s disease, or prolonged immobility. Key risk factors include age-related degeneration of the otolithic membrane, female gender, osteoporosis, hypertension, elevated cholesterol, and vitamin D deficiency. Long-term proton pump inhibitor use and poor sleep or inactivity may also contribute. A growing body of evidence also supports an association between BPPV and migraine.

Recurrence is linked to systemic conditions such as diabetes, hyperlipidemia, and hypertension. Vitamin D deficiency and osteoporosis are strongly correlated.  Managing metabolic health and bone density may reduce recurrence risk.

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Prevelance 

BPPV has a lifetime prevalence of approximately 2.4%, with an annual incidence around 0.6%, making it the most common peripheral vestibular disorder in adults. Prevalence increases markedly with age, affecting up to 10% of individuals over 70 years old.  BPPV shows a clear female predominance, with a reported female-to-male ratio of 2:1. These figures are supported by population-based studies, including von Brevern et al., (2007). 

Types of BPPV

Percent of BPPV Cases 

A recent large cross-sectional study by of 3,975 patients by Bhandari et al. in 2023, found that posterior canal BPPV (pc-BPPV) accounted for 47.8% of cases, while horizontal canal BPPV (hc-BPPV) was nearly as common at 46.3%. This contrasts with older studies that reported posterior canal dominance, likely due to small sample sizes and underuse of the supine roll test. The findings highlight the importance of performing both Dix-Hallpike and supine roll tests to improve diagnostic accuracy.

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Patient Reported Symptoms 

  • Typically a sudden onset of vertigo/dizziness with certain head movements
  • Additionally nausea, imbalance, lightheadedness, and even falls
  • Brief episodes lasting only seconds to minutes
  • Crescendo and Decrescendo pattern
  • Movement Triggers
    • Laying into and getting out of bed
    • Rolling over in bed
    • Looking / Reaching up, bending over
  • Symptoms typically worse in the morning and improve as day progresses

However…

Recent research shows that patients with BPPV do not always experience or report vertigo — a term called vestibular agnosia. This is particularly common after concussion or brain injury and in older adults. For this reason, experts recommend that all adults over 60 with either objective or subjective balance problems undergo positional testing for BPPV, even if they deny dizziness or vertigo. Prevalence studies suggest that about 9% of community-dwelling older adults have BPPV, underscoring the need for routine screening in this population (Li et al., 2023; Balatsouras et al., 2018; Hassett 2024). 

Clinical Findings 

  • Abnormal findings on positional tests, that may include the Dix-Hallpike test or supine roll test 

  • Postural Instability, especially with eyes closed or head turns

  • Oculomotor Examination

    • Spontaneous Nystagmus – could be present if BPPV is in a horizontal canal

    • Abnormal Head Impulse Test (HIT) – could be abnormal if BPPV started with concurrent acute unilateral vestibular hypofunction, otherwise typically negative

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Want to learn more about BPPV? – Check out these resources 

References 

  • Balatsouras DG, Koukoutsis G, Fassolis A, Moukos A, Apris A. Benign paroxysmal positional vertigo in the elderly: Current insights. Clin Interv Aging. 2018;13:2251-2266. https://pmc.ncbi.nlm.nih.gov/articles/PMC6223343/

  • Bhandari R, Bhandari A, Hsieh YH, Edlow J, Omron R. Prevalence of Horizontal Canal Variant in 3,975 Patients With Benign Paroxysmal Positional Vertigo: A Cross-sectional Study. Neurol Clin Pract. 2023 Oct;13(5):e200191. doi: 10.1212/CPJ.0000000000200191. Epub 2023 Aug 23. PMID: 37664131; PMCID: PMC10473829. https://pubmed.ncbi.nlm.nih.gov/37664131/

  • Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: Benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599816689667

  • Chen J, Zhao W, Yue X, Zhang P. Risk Factors for the Occurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis. Front Neurol. 2020 Jun 23;11:506. doi: 10.3389/fneur.2020.00506. PMID: 32655479; PMCID: PMC7324663. https://pubmed.ncbi.nlm.nih.gov/32655479/

  • Fife TD, Iverson DJ, Lempert T, 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):2067-2074.

  • Fu CY, Zhang ZZ, Chen J, Jaiswal SK, Yan FL. Unhealthy lifestyle is an important risk factor of idiopathic BPPV. Front Neurol. 2020;11:950. https://pmc.ncbi.nlm.nih.gov/articles/PMC7593564/?utm_source

  • Hassett, P. Incidence of Vestibular Dysfunction in Frail Older Adults Attending an Integrated Care Programme for Older Persons (ICPOP), Age and Ageing, Volume 53, Issue Supplement_4, September 2024, afae178.341. https://doi.org/10.1093/ageing/afae178.341
  • Kalmanson O, Foster C. Epley’s Influence on Horizontal Canal BPPV Variants. Audiol Res. 2025 Mar 7;15(2):25. doi: 10.3390/audiolres15020025. PMID: 40126273; PMCID: PMC11932226. https://pmc.ncbi.nlm.nih.gov/articles/PMC11932226/

  • Lee JH, Kim SY, Kim HJ. Benign paroxysmal positional vertigo is associated with an increased risk for migraine diagnosis: A nationwide population-based cohort study. Int J Environ Res Public Health. 2023;20(4):3563. https://www.mdpi.com/1660-4601/20/4/3563?utm_source

  • Li Y, Smith RM, Whitney SL, Seemungal BM, Ellmers TJ. We should be screening for benign paroxysmal positional vertigo (BPPV) in all older adults at risk of falling: a commentary on the World Falls Guidelines. Age Ageing. 2023 Nov 2;52(11):afad206. doi: 10.1093/ageing/afad206. https://pubmed.ncbi.nlm.nih.gov/37979182/

  • Li Y, Gao P, Ding R, et al. Association between vitamin D, vitamin D supplementation and benign paroxysmal positional vertigo: A systematic review and meta-analysis. Front Neurol. 2025;16:1560616. https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2025.1560616/full

  • Tang B, Zhang C, Wang D, Luo M, He Y, Xiong Y, Yu X. Development and verification of a nomogram for recurrence risk of Benign Paroxysmal Positional Vertigo in middle-aged and older populations. Front Neurol. 2024 Dec 13;15:1483233. https://pubmed.ncbi.nlm.nih.gov/39734629/

  • von Brevern M, Bertholon P, Brandt T, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. J Vestib Res. 2015;25(3-4):105-117. https://pubmed.ncbi.nlm.nih.gov/26756126/

  • von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: A population based study. J Neurol Neurosurg Psychiatry. 2007;78(7):710-715. https://pubmed.ncbi.nlm.nih.gov/17135456/

  • Yang B, Lu Y, Xing D, Zhong W, Tang Q, Liu J, Yang X. Association between serum vitamin D levels and benign paroxysmal positional vertigo: a systematic review and meta-analysis of observational studies. Eur Arch Otorhinolaryngol. 2020 Jan;277(1):169-177. doi: 10.1007/s00405-019-05694-0. Epub 2019 Oct 19. PMID: 31630244. https://pubmed.ncbi.nlm.nih.gov/31630244/