GPAtlas🧭 When to suspect (and when to doubt it)
Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. It arises when displaced otoconia (calcium-carbonate “ear crystals”) drift into a semicircular canal – the posterior canal in around 85–90% of cases – so that a change in head position relative to gravity sets off a brief, intense illusion of spinning.
The hallmark is short-lived vertigo (typically 20–30 seconds, rarely beyond a minute) triggered by specific movements: rolling over in bed, lying down, sitting up, or looking up. Symptoms settle completely between attacks (some residual unsteadiness is allowed), and there is no hearing loss or tinnitus. It is benign and self-limiting, but recurs in roughly one in three people within a year.
The two clinical skills that matter in primary care are simple: confirm the diagnosis with the Dix–Hallpike manoeuvre (a positional-vertigo history alone is not enough), and exclude a central mimic. The pattern below is the safest way to keep both in view.
| Points towards BPPV | Points away – think alternative or central cause |
|---|---|
|
• Brief vertigo (seconds to <1 minute) triggered by a change in head position |
• Continuous or spontaneous vertigo lasting minutes to hours, or present at rest |
|
• Symptom-free between attacks (mild residual unsteadiness acceptable) |
• New or progressive hearing loss, tinnitus or aural fullness (consider Ménière's, vestibular schwannoma) |
|
• Normal hearing, no focal neurology |
• Focal neurology, new headache or gait ataxia – especially with vascular risk factors |
|
• Positive Dix–Hallpike – torsional, up-beating nystagmus with latency that fatigues |
• Nystagmus that is vertical, direction-changing, without latency, or non-fatiguing |
Source: AAO-HNS BPPV Clinical Practice Guideline · Bárány Society diagnostic criteria
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