Benign paroxysmal positional vertigo (BPPV), was considered the most common cause of dizziness before recognition of migraine associated dizziness as the most common cause of dizziness. This happens with otoconia, which are calcium carbonate crystals normally found in part of the inner ear called the utricle and saccule – which sense acceleration, fall off and get into the semicircular canals – the part of the inner ear that senses rotation.
Usually, one ear is affected, and typically, the posterior semicircular canal is the involved semicircular canal. When a patient has this, he or she will usually have spinning vertigo that is triggered by lying down in bed, turning over in bed, bending over, or looking up. It usually lasts less than a minute and will go away. When the eyes are examined during an episode, it typically would have a repeated rotary movement called nystagmus until the vertigo goes away.
Some patients will also have a feeling of unsteadiness when they are not having the episodes of vertigo. Often, with regular activity, the otoconia will dissolve and over time, the patient will no longer have episodes of vertigo, but it can certainly remain and continue to cause problems.
When I see a patient that has this problem, I will typically instruct the patient to do some exercises called the Canalith Repositioning Procedure, or Epley maneuver, at home, if the patient is able, to help clear the otoconia from the involved semicircular canal. The written-out exercise for posterior canal BPPV follows here:
Right Canalith Repositioning Procedure (for right posterior canal BPPV)
1) Lie down on the left half of your bed and turn your head 45 degrees to the right of the vertical axis with the chin up. You may have vertigo in this position. Wait here for 1 minute.
2) Turn your head 90 degrees to the left so that it is 45 degrees to the left relative to the vertical axis, with the chin up. Wait here for 1 minute.
3) Turn onto your left shoulder and point your nose towards the floor. Wait here for 1 minute. You may get dizziness in this position.
4) Without rolling back onto your back, bring your legs off of the left side of the bed and sit up, and lean forward some while tucking your chin. If you did not get dizziness with position 3, you may have dizziness here. Wait 1 minute.
Left Canalith Repositioning Procedure (for left posterior canal BPPV)
1) Lie down on the right half of your bed and turn your head 45 degrees to the left of the vertical axis with the chin up. You may have vertigo in this position. Wait here for 1 minute.
2) Turn your head 90 degrees to the right so that it is 45 degrees to the right relative to the vertical axis, with the chin up. Wait here for 1 minute.
3) Turn onto your right shoulder and point your nose towards the floor. Wait here for 1 minute. You may get dizziness in this position.
4) Without rolling back onto your back, bring your legs off of the right side of the bed and sit up, and lean forward some while tucking your chin. If you did not get dizziness with position 3, you may have dizziness here. Wait 1 minute.
Try to do this exercise 1-2 times a day for 2 weeks. As your problem improves, you may not get any more dizziness in any of the positions during this exercise.
Here is a great website from Dr. Teixido about BPPV with excellent diagrams and demonstration videos:
https://entad.org/resources/patient-information-dr-teixido/bppv/
Here is also a great website from Dr. Hain on BPPV:
https://dizziness-and-balance.com/disorders/bppv/bppv.html
Sometimes a different semicircular canal is involved. The second most common involved canal is the horizontal (lateral) semicircular canal. With this, the vertigo can actually be more intense. In contrast to posterior canal BPPV, horizontal canal BPPV can cause dizziness in both the head right and left positions. Sometimes, when an Epley maneuver (canalith repositioning procedure) for posterior canal BPPV is performed, it can induce horizontal canal BPPV if the otoconia get into the lateral canal. It is important to be aware of this possibility and know the exercise that should be helpful for it.
The log roll exercise is the maneuver that I have found most helpful for my patients who develop horizontal canal BPPV.
Log roll exercise for right horizontal canal BPPV:
1) Lie down on your right side with the right ear down onto the pillow. The head can be along the horizontal axis. You will likely be dizzy in this position. Wait here about 1 minute.
2) Turn your head and body 90 degrees to the left so that you are flat on your back with your nose pointed straight towards the ceiling. Wait here 1 minute.
3) Turn another 90 degrees to the left so that you are lying down on your left side with the left ear down, and the head oriented along the horizontal axis. Wait here about 1 minute.
4) Turn another 90 degrees to the left so that you are face down, and get onto your hands and knees. Wait here about 1 minute.
Log roll exercise for left horizontal canal BPPV:
1) Lie down on your left side with the left ear down onto the pillow. The head can be along the horizontal axis. You will likely be dizzy in this position. Wait here about 1 minute.
2) Turn your head and body 90 degrees to the right so that you are flat on your back with your nose pointed straight towards the ceiling. Wait here 1 minute.
3) Turn another 90 degrees to the right so that you are lying down on your right side with the right ear down, and the head oriented along the horizontal axis. Wait here about 1 minute.
4) Turn another 90 degrees to the right so that you are face down, and get onto your hands and knees. Wait here about 1 minute.
Try to repeat the exercise 1-2 times a day for 2 weeks.
Sometimes, it is difficult to tell which ear is the involved ear in horizontal canal BPPV, as patients can have vertigo with both the right and the left ear down. Usually, we will choose the side that was first involved with posterior canal BPPV and do the log roll exercise for that same side. However, if we do not know, typically, the side that has the most intense vertigo is the involved ear. For example, if when you lie down on your right side with the right ear down and the vertigo is more intense in this position than when you lie down on the left side with the left ear down, it is more likely that the right ear is the involved ear and the right sided log roll maneuver can be done.
Occasionally, we will just have patients do the procedure for both the right and the left ears if we cannot figure out which side is involved.
Please look at Dr. Hain’s very helpful website (with diagrams) on horizontal canal BPPV:
https://dizziness-and-balance.com/disorders/bppv/lcanalbppv.htm
There are also patients who have refractory or frequently recurring BPPV that either only get better for a short period of time with the proper exercises or who never get much improvement with the proper exercises. In this circumstance, I typically treat for migraine associated dizziness. The hypothesis for why this happens is that migraine activity along the vestibular nerves can impact the inner ear itself at the cellular level, affecting the utricle and saccule. The cells supporting the otoconia can become dysfunctional, causing repeated shedding of the otoconia and, in turn, repeated or refractory BPPV.
There are also some surgical procedures that can be performed for refractory BPPV. These are very rarely done nowadays, especially with the recognition that treatment for migraine can be helpful in patients who have recurrent or refractory BPPV.
Brian Kung, MD 