Treatment of benign paroxysmal positional vertigo (BPPV)

1. Big picture

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo and one of the most exam-friendly vestibular topics because the diagnosis and treatment are mainly clinical.

The key idea is simple:

Short attacks of vertigo triggered by head position = think BPPV. Treat by repositioning the otoliths, not by chronic drugs.

BPPV is “benign” because it is not a stroke or tumor, “paroxysmal” because it occurs in brief attacks, and “positional” because it is provoked by specific head positions.

The examiner usually wants you to know:

• how to recognize BPPV clinically,

• how to confirm it with the Dix-Hallpike maneuver,

• that the usual mechanism is canalolithiasis of the posterior semicircular canal,

• that treatment is Epley or Semont repositioning maneuver,

• that vestibular suppressants are not the real treatment,

• and that vertical/persistent/neurologically associated nystagmus suggests central disease, not simple BPPV.