Clinical Guide to BPPV diagnosis and Treatment

Quick Master BPPV Reference Chart 

This chart summarizes common BPPV diagnoses and related treatment options. Note that nystagmus direction is described in relation to the patient’s perspective. For example, if the patient’s eyes beat horizontally with the fast beat to patient’s right, this is named as a right-beating nystagmus.

If nystagmus and/or symptoms do not improve or ideally resolve after 1–2 well-applied maneuvers, strongly consider switching to a different maneuver type. If the positional nystagmus and/or symptoms persist after 3-5 well-applied different maneuvers, reconsider your BPPV diagnosis and examine alternative diagnoses such as central vestibular pathology (e.g. vestibular migraine).

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 towards affected side, 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/ SemontPLUS Dias Li Universal Sleep Maneuver Gans Brandt-Daroff Foster
Posterior cupulolithiasis	Upbeating-torsional nystagmus towards affected side, 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/ SemontPLUS	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 for canalithiasis	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 for cupulolithiasis Kim (CuRM) Zuma Square Wave Kurtzer Hybrid Head Shaking
Anterior canalithiasis	<1 min downbeating positional nystagmus, may have torsion towards affected side (An example of downbeating right torsion)	Dix-Hallpike or Straight Head Hanging Test	Torsion (if present) is thought to rotate towards the affected side	Yacovino/ Modified Yacovino	Garaycochea Modified Epley Bascule Short CRP Brandt-Daroff
Short-arm posterior canalithiasis	No classic findings, may include any of the following: 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	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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Get the quality, affordable infrared video goggles (video Frenzels) you deserve — visit v1st.co/store to purchase today.
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