Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is a common cause of recurrent episodes of vertigo triggered by head movement. It is a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain. It is more common in older adults.



A variety of head movements can trigger attacks of vertigo. A common trigger is turning over in bed. Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks. Often episodes occur over several weeks and then resolve but can reoccur weeks or months later.

BPPV does not cause hearing loss or tinnitus.



BPPV is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. This occurs most often in the posterior semicircular canal. They may be displaced by a viral infection, head trauma, ageing or without a clear cause. 

The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.


Dix-Hallpike Manoeuvre

The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis). It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV. Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology.

To perform the manoeuvre:

  • The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
  • Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
  • Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
  • Watch the eyes closely for 30-60 seconds, looking for nystagmus
  • Repeat the test with the head turned 45 degrees in the other direction


In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).


Epley Manoeuvre

The Epley manoeuvre can be used to treat BPPV. The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow.

To perform the manoeuvre:

  • Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
  • Rotate the patient’s head 90 degrees past the central position
  • Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
  • Have the patient sit up sideways with the legs off the side of the couch
  • Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
  • At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle


TOM TIP: Watch videos of the Dix-Hallpike and Epley manoeuvres and practice performing them on your friends. It is worth remembering the names, indications and interpretation, which may be tested in your MCQ exams. I would be surprised if you are asked to perform the manoeuvres in your OSCEs. However, it is worth learning how to perform them as they are not too difficult, and you can impress patients, friends, relatives or seniors if you can perform them at will.


Brandt-Daroff Exercises

Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.


Last updated July 2021