Vexatious Vertigo

Invigorate Health and Performance, Vexatious vertigo

Benign Paroxysmal Positional Vertigo, otherwise known as BPPV- you might be thinking “woah, what on earth is that?!” – is a condition which affects the inner ear and results in vertigo (dizziness), nystagmus (involuntary eye movements) and nausea. It is the most common cause of dizziness. If we break down the meaning of BPPV, benign stands for not dangerous or life threatening, paroxysmal meaning rapid or short, positional referring to it being caused by head positions and finally vertigo meaning dizziness. In 80% of cases there is no known cause, however, it is associated with things such as head trauma, migraines, post-operative complication to the inner ear, vestibular neuritis, stress or anxiety and is strongly linked with older age. About 50% of all dizziness in older people is due to BPPV. Fortunately for those affected, this condition can improve and physiotherapists can provide treatment.



So what exactly is BPPV and how does it occur?

To makes things simple let’s get stuck into some basic anatomy. In the image below you can see within the inner ear there are 3 canals called the semi-circular canals. There is also a structure in the inner ear called the utricle which contains little ‘ear rocks’ or formally known as otoconia. Normal functioning would generally see the otoconia positioned within the utricle to ensure correct functioning of the vestibular system, however, what occurs during BPPV is these small little ‘rocks’ or otoconia dislodge into one of the 3 semi-circular canals. You can see this in the image where it says “displaced otoconia” showing the otoconia sitting within the semi-circular canals. When these otoconia move into the semi-circular canals it causes the canals to be inappropriately excited and thereby falsely convey you are moving more than you actually are. This misinterpretation triggers the onset of vertigo and nystagmus.




In terms of the canals which are most affected, 85-95% of BPPV occurs in the posterior canal. 5-15% occurs within the horizontal canal and 1-5% occurs in the anterior canal (rare).



So how does a physiotherapist assess whether you have BPPV?

A physiotherapist who is trained in BPPV will take you through a range of manoeuvres to assess each of the 3 canals. There are different tests for each canal as follows:

  • Dix Hallpike – anterior and posterior canal
  • Roll test – horizontal canal

Interested in what these tests look like? My suggestion would be to YouTube the above tests as I find a written explanation can be difficult to understand.

Treatment for BPPV also has specific manoeuvres for each canal as follows:

  • Epley – posterior and anterior canal
  • Semont/liberatory– posterior and anterior canal
  • BBQ roll – horizontal canal
  • Gufoni – horizontal canal



What is the likelihood of my BPPV symptoms improving?

Treatment is effective if the patient’s source of BPPV has been identified correctly (i.e., which semi-circular canal is affected) and the correct treatment for that canal is performed. Unfortunately, not all sources of vertigo are BPPV related meaning referral to a specialist may be required if treatment does not improve symptoms.

In a study by Macias and colleagues, it looked at 259 BPPV patients who received the Epley manoeuvre and results suggested 74.8 percent required only one treatment, 19 percent required two treatments and 98.4 percent of patients were successfully treated after three sessions (Macias et al., 2000).  Salvinilli and colleagues found that the liberatory manoeuvre had good results. They found there was a remission rate of 92.5 percent with one manoeuvre while the untreated control group had a remission rate of 37.5 percent (Salvinelli et al., 2003). To surmise, there is evidence that treatment of BPPV does work so if you are experiencing symptoms of vertigo it is best to get checked out!




  1. Macias, J., Lambert, K., Massingale, S., Ellensohn, A., & Ann Fritz, J. (2000). Variables Affecting Treatment in Benign Paroxysmal Positional Vertigo. The Laryngoscope, 110(11), 1921-1924. doi: 10.1097/00005537-200011000-00029
  2. Salvinelli, F., Casale, M., Trivelli, M., D’Ascanio, L., Firrisi, L., Lamanna, F et al. (2003). Benign paroxysmal positional vertigo: a comparative prospective study on the efficacy of Semont’s maneuver and no treatment strategy. Clin Ter, 154(1):7-11.



Written by William Lewis (Physiotherapist)