Clinical Guide to BPPV Presentation and Treatment

Summary Chart

This chart summarizes common BPPV presentations and typical treatment options. It is not intended to cover every atypical or complex case. Nystagmus should be named from the patient’s perspective. If nystagmus does not resolve after 1–3 well-applied maneuvers, consider changing maneuvers. If symptoms or nystagmus persist after 3–5 treatment sessions, consider alternative diagnoses such as central pathology or vestibular migraine and proceed with appropriate next steps.

BPPV Type	Classic Nystagmus Pattern	Positional Tests	How to Identify The Affected Side	Evidence-Supported First-Line Maneuver	Other Possible Maneuvers
Posterior canalithiasis (long arm variant)	Upbeating-torsional nystagmus lasting <1 minute during testing (An example of upbeating with right torsion)	Dix-Hallpike or Sidelying test	The torsional component rotates toward the affected ear. The affected side is often, but not always, the side that produces stronger symptoms during testing.	Modified Epley	Semont/ Semont-Plus Dias Li Universal Sleep Maneuver Gans Brandt-Daroff Foster
Posterior cupulolithiasis	Upbeating-torsional nystagmus lasting >1 minute during testing (An example of upbeating right torsion)	Dix-Hallpike or Sidelying test	The torsional component rotates toward the affected ear. The affected side is often, but not always, the side that produces stronger symptoms during testing.	Semont/ Semont-Plus	Quick Liberatory Rotation Bascule Brandt-Daroff Sleep Maneuver Head shaking
Horizontal canalithiasis	Geotropic (towards the ground) horizontal nystagmus	Supine Roll Test	Affected side: usually stronger nystagmus/ symptoms If unclear: use bow-and-lean or seated-supine test	Gufoni	Modified Zuma Li Quick Roll Forced Prolonged Position BBQ Roll/ Lempert Kurtzer Hybrid  Square Wave
Horizontal cupulolithiasis	Apogeotropic/ ageotropic (away from ground) horizontal nystagmus	Supine Roll Test	Affected side: usually weaker nystagmus/ symptoms If unclear: use bow-and-lean or seated-supine test	Forced Prolonged Position	Gufoni Kim (CuRM) Zuma Square Wave Kurtzer Hybrid Head Shaking
Anterior canalithiasis	<1 min downbeating positional nystagmus, may have torsion (An example of downbeating right torsion)	Dix-Hallpike or Straight Head Hanging Test	Torsion (if present) is thought to rotate towards the affected side Side of involvement can be difficult to determine	Yacovino/ Modified Yacovino	Garaycochea Modified Epley Bascule Short CRP Brandt-Daroff
Short-arm posterior canal	Downbeat/ downbeat-torsional nystagmus on testing Brief symptoms without nystagmus Nystagmus reverses on sitting up Persistent posterior canal–like findings after Epley/ Semont	Dix-Hallpike or Straight Head Hanging Test	Torsion (if present) is thought to rotate towards unaffected side Side of involvement can be difficult to determine	Yacovino/ Modified Yacovino	Garaycochea Farouk Praying Maneuver Bow and Yaw Bascule Rapid bilateral sitting-up Brandt-Daroff

Why Use Infrared Video Goggles?

Accurate BPPV assessment depends on the ability to clearly observe nystagmus. Research shows that abnormal eye movements are often missed with room-light observation or traditional thickened Frenzel lenses alone. Infrared video goggles remove visual fixation, improve visualization of subtle or atypical nystagmus, and help clinicians more confidently identify the involved canal, select the appropriate maneuver, and recognize when findings suggest a more complex presentation.

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