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Last Updated: 12/13/2012  

Benign Paroxysmal Positional Vertigo

Diagnosis
  • Obtain a history of vertigo that occurs when turning in bed or tilting the head backward and lasts 10 to 30 seconds.

  • Ask about symptoms such as hearing loss, tinnitus, weakness, and numbness of the face or limbs, which suggest an alternative etiology.

  • Look for physical exam findings that suggest a peripheral cause of vertigo compatible with BPPV, such as spontaneous nystagmus, gaze-invoked nystagmus, a positive head thrust test, and abnormal Dix-Hallpike maneuver.

  • Look for physical exam findings that suggest a central cause of vertigo not compatible with BPPV, such as cranial nerve dysfunction and brainstem dysfunction.

  • Obtain basic vestibular laboratory testing in patients with atypical dizziness or vertigo between attacks of typical BPPV.

  • Obtain MRI scan of the head and internal auditory canals to exclude structural lesions in patients with cranial nerve or brainstem dysfunction; hearing loss, tinnitus or ear fullness; downbeating rather than upbeating nystagmus during Dix-Hallpike maneuvers; persistent symptoms and signs during Dix-Hallpike maneuvers; or in case of failure to respond to conservative management.

Therapy
  • Perform particle-repositioning maneuver immediately after a positive Dix-Hallpike test.

  • Instruct selected patients on how to perform particle repositioning at home.

  • Prescribe home Brandt-Daroff exercises for patients with BPPV who cannot tolerate particle repositioning.

  • Enroll older patients predisposed to falls in a course of vestibular rehabilitation therapy.

  • Prescribe vestibular suppressant medications such as meclizine for patients with severe nausea and vomiting, understanding that such medications do not prevent attacks of BPPV.

  • Assess individual benefit and harm of anxiolytic medication such as a benzodiazepine for treatment of anxiety associated with BPPV.

  • Obtain consultation with a surgical otologist/neurosurgeon for patients with disabling symptoms.

DOI: 10.7326/d310
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Disclosures:
Joseph M. Furman, MD received honorarium from The American Academy of Neurology, and received grants from Merck. Philip Masters, MD, FACP American College of Physicians
Philadelphia, PA
has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Deborah Korenstein, MD, FACP, Editor in Chief, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Richard B. Lynn, MD, FACP, Editor, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
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