Vertigo and BPPV: Why the Room Spins and What Can Be Done About It

The most common cause of sudden spinning vertigo — particularly when triggered by rolling over in bed or looking up — is BPPV (Benign Paroxysmal Positional Vertigo), a highly treatable condition caused by displaced crystals in the inner ear. In most cases a single clinic visit and the Epley repositioning manoeuvre performed by an ENT specialist is sufficient to resolve it completely.

• BPPV is the most common cause of sudden spinning vertigo, particularly triggered by rolling over in bed or looking up

• It is caused by displaced calcium crystals in the semicircular canals of the inner ear

• A single clinic visit and the Epley repositioning manoeuvre is usually sufficient to resolve it completely

• It is highly treatable with no medication required in most cases

BPPV occurs when tiny calcium crystals become displaced within the semicircular canals of the inner ear, sending false signals to the brain and producing the characteristic spinning sensation triggered by head movement.

Vertigo is one of the most disorienting and frightening symptoms a patient can experience. The sudden sensation that the room is spinning — or that you are spinning within it — can be entirely incapacitating, and when it strikes without warning, it understandably causes significant anxiety. It can present alone or with other symptoms such as tinnitus, nausea and hearing loss.

The good news is that the most common cause of vertigo — benign paroxysmal positional vertigo, or BPPV — is highly treatable. In many cases, a single clinic visit and a specific repositioning manoeuvre performed by an ENT specialist is sufficient to resolve it completely.

This article explains what BPPV is, how it differs from other causes of vertigo and dizziness, how it is diagnosed, and what treatment involves.

Vertigo Versus Dizziness: An Important Distinction

These terms are often used interchangeably, but they describe different sensations and have different causes.

Dizziness is a broad term that covers lightheadedness, unsteadiness, or a feeling of being about to faint. It often has cardiovascular, neurological, or medication-related causes and is not primarily an ENT problem.

Vertigo is a specific sensation of movement — typically spinning — when no movement is actually occurring. It is caused by a mismatch between the signals the brain receives from the inner ear, the eyes, and the body's sensory system. When vertigo is the presenting symptom, the inner ear is usually the place to start looking.

What Is BPPV?

BPPV — benign paroxysmal positional vertigo — is the most common cause of vertigo I see in clinic. It accounts for around a third of all vertigo presentations.

It occurs when small calcium carbonate crystals — called otoconia or "ear rocks" — that normally sit on a sensory structure in the inner ear (the utricle) become displaced and migrate into one of the three fluid-filled semicircular canals. These canals detect head rotation. When crystals are present within them, normal head movements generate abnormal fluid currents and send erroneous signals to the brain — producing the sensation of spinning.

The condition is called:

• Benign — it is not dangerous and does not cause permanent damage

• Paroxysmal — the episodes are sudden and brief, typically lasting less than a minute

• Positional — it is triggered by specific head positions or movements

What Does BPPV Feel Like?

The classic presentation is a sudden, brief, intense episode of spinning vertigo triggered by a specific movement — most commonly rolling over in bed, sitting up from lying down, looking up, or bending forward. The sensation typically begins a few seconds after the movement and lasts for less than a minute, though the feeling of unsteadiness afterward may persist for longer.

Patients often describe a very specific trigger position and learn quickly which movements to avoid. Nausea frequently accompanies the episode, and some patients vomit during severe attacks. Between episodes, many patients feel completely normal, though mild unsteadiness or a swimmy feeling may persist.

BPPV can affect any age group but is most common in adults over forty. It may occur spontaneously, after a head injury, following a period of prolonged bed rest, or after an inner ear infection. Often no specific trigger is identified.

Other Causes of Vertigo

While BPPV is the most common cause, other conditions can produce vertigo and need to be considered in assessment:

Vestibular Neuritis

An inflammation of the vestibular nerve — usually following a viral illness — that causes a sudden onset of severe, persistent vertigo lasting days to weeks, gradually improving as the brain compensates. Unlike BPPV, the vertigo is not positional and does not come in brief episodes.

Ménière's Disease

A condition of the inner ear characterised by recurrent episodes of severe rotational vertigo lasting minutes to hours, accompanied by fluctuating hearing loss, tinnitus, and a sensation of fullness in the affected ear. Episodes are unpredictable and can be significantly disabling.

Labyrinthitis

Inflammation of the labyrinth (inner ear), usually viral, causing acute vertigo alongside hearing loss — distinguishing it from vestibular neuritis where hearing is preserved.

Central Causes

Less commonly, vertigo originates from the brain rather than the inner ear — from conditions affecting the cerebellum or brainstem. Central vertigo is typically associated with other neurological symptoms such as double vision, difficulty swallowing, or limb weakness, and requires neurological investigation. Distinguishing peripheral (inner ear) from central vertigo is an important part of clinical assessment.

How Is BPPV Diagnosed?

Diagnosis of BPPV is clinical — it does not require scans or blood tests in most cases. The key diagnostic test is the Dix-Hallpike manoeuvre, performed in clinic.

The patient is moved from a seated position to lying with the head turned to one side and extended slightly over the edge of the examination couch. In a patient with BPPV affecting the posterior semicircular canal — the most common type — this provokes a characteristic burst of rotational nystagmus (a specific eye movement pattern) accompanied by the patient's typical vertigo. The response is delayed by a few seconds, lasts less than a minute, and fatigues on repetition.

The pattern of nystagmus tells me which canal is affected and guides which repositioning manoeuvre to use. For horizontal canal BPPV, a roll test is used instead.

Treatment: The Epley Manoeuvre

The Epley manoeuvre is the primary treatment for posterior canal BPPV — the most common type — and it is performed in clinic without any special equipment.

The principle is straightforward: by moving the head through a specific sequence of positions, the displaced crystals are guided out of the semicircular canal and back into the utricle where they cause no further symptoms.

The manoeuvre involves four or five sequential head positions, each held for around thirty seconds.

Most patients experience their characteristic vertigo during the manoeuvre as the crystals move through the canal. This is expected and indicates the treatment is working.

The success rate of a single Epley manoeuvre is around 80% for posterior canal BPPV. Some patients require a second treatment at a follow-up visit. In cases that do not respond, the diagnosis and canal involved are reassessed.

After the manoeuvre, patients are advised to avoid lying flat for the rest of the day and to sleep with the head slightly elevated for the first night. Normal activities can resume immediately.

For horizontal canal BPPV, a different manoeuvre — the Barbecue roll or Gufoni manoeuvre — is used. This variant is less common but equally treatable.

When Does Vertigo Require Further Investigation?

Most cases of BPPV can be diagnosed and treated at the first appointment without any investigations. However, further assessment is indicated when:

• The presentation is atypical or the nystagmus pattern does not fit BPPV

• There are associated neurological symptoms such as weakness, double vision, or difficulty speaking

• Hearing loss or tinnitus accompanies the vertigo — raising the possibility of Ménière's disease or labyrinthitis

• The vertigo is severe, persistent, and not positional

• The Epley manoeuvre does not produce the expected response

In these situations, audiometry, MRI imaging, and vestibular function tests may be arranged.

Can BPPV Come Back?

Yes. Recurrence is common — around half of patients experience at least one further episode within five years. Recurrent BPPV can be treated in exactly the same way as the initial episode. Some patients find it helpful to learn a modified version of the manoeuvre to perform at home if symptoms recur, and I am happy to teach this where appropriate.

Living With Vertigo While Awaiting Assessment

If you are experiencing acute vertigo, a few practical points:

• Avoid sudden head movements that trigger the spinning

• Take particular care on stairs, in the dark, and when driving — do not drive during active episodes

• Stay hydrated

• Over-the-counter vestibular sedatives may provide short-term symptom relief but do not treat the underlying cause and should not be used long-term

• Seek prompt ENT assessment — BPPV is highly treatable and there is no benefit in waiting

Book a Vertigo Assessment

If you are experiencing episodes of spinning vertigo, particularly triggered by head movement, an ENT assessment can usually establish the cause and offer effective treatment at the same visit.

Dr Vyas Prasad consults at Absolute ENT, Camden Medical Centre, 1 Orchard Boulevard, #09-08, Singapore. Contact the clinic by WhatsApp on +65 8060 8079 or by email at camden.mmc@gmail.com.