Essential Skills for Managing Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness and vertigo.1-4 The condition is characterized by brief episodes of dizziness, nausea, and/or nystagmus triggered by head movement.5 Over 7 percent of the population will experience BPPV at some point in their lifetime and 80 percent of those patients will require medical treatment.6,7

Chiropractors are uniquely suited to differentiate BPPV from the similar-looking cervicogenic vertigo. Both conditions are very amenable to treatment; however, each is managed quite differently. Successful outcomes are predicated upon a solid understanding of both.

Watch this quick tutorial video to hone your skills for the current evidence-based assessment and management of Benign Paroxysmal Positional Vertigo (BPPV).


The classic presentation for BPPV includes sudden (aka paroxysmal) episodes of rotary vertigo that last 10-20 seconds following head position changes.5,8 Typical provocative activities involve transitioning between upright and recumbent positions; rolling from side to side in bed; bending forward; and moving the head to look up, down, or side to side.9


The primary purpose of the clinical exam is twofold; first, to rule out more sinister causes of vertigo, and second, to identify the side (right, left, both) and site (posterior, anterior, horizontal) of the involved semicircular canal. Clinicians should keep in mind that multiple canals can be involved (4.6 percent of cases) and the condition can be bilateral.10-11

Most cases of BPPV affect the posterior semicircular canal.12-13 The Dix-Hallpike maneuver is the gold standard for diagnosing posterior semicircular canal involvement.14-17 The test has a specificity of 83 percent and sensitivity of 52 percent for BPPV arising from the posterior semicircular canal.18-19

BPPV symptoms are generally episodic, provoked by movement and eased by maintaining a stable position. Continuous symptoms or nystagmus that occurs without changing head position suggests central pathology.20,21 Clinicians should search for clues that suggest a non-BPPV origin, including a history of head trauma, loss of consciousness, frequent unexplained falls, hearing loss, tinnitus, ear “fullness”, earache, ptosis, facial or extremity paresthesia, visual disturbances, difficulty speaking, difficulty swallowing, ataxia, or a new medication, particularly anti-hypertensives or anti-depressants.


Cervicogenic vertigo presents with symptoms similar to BPPV, i.e., episodic, provoked by movement, and eased by maintaining a stable position. Patients may complain of light-headedness, floating, unsteadiness, or general imbalance, but rarely true “spinning” vertigo22. Cervicogenic vertigo is often accompanied by loss of cervical range of motion, upper cervical tenderness, and upper cervical segmental joint restriction.23,24

One complicating factor for differentiating cervicogenic vertigo from BPPV is that most provocative movements concurrently stimulate both cervical spine proprioceptors and the vestibular apparatus. The Head-fixed/body-turn test (aka Neck torsion test) aims to isolate cervical mechanoreceptors without stimulating the vestibular apparatus.25,26 The neck torsion test is performed with the patient rotating their body on an exam stool while the clinician stabilizes their head, thereby minimizing vestibular input. Reproduction of dizziness or nystagmus when the head is stable suggests a cervical component.27-29


Canalith repositioning maneuvers and home-based exercise are the current standard of care for BPPV.12,14,15,19,30 Management is predicated upon first identifying the involved semicircular canal(s), and then choosing the appropriate maneuver to reposition the wayward calcium carbonate sediment.2,9 All repositioning maneuvers attempt to move the head into a position where debris can fall to the top of the problematic canal and then transition the head into a position where the debris moves around the canal back into the vestibule.

When the posterior semicircular canal is involved, clinicians should choose the canalith repositioning procedure, aka, Epley maneuver.14-16 The effectiveness of the Epley maneuver ranges between 78-95 percent.31 A single intervention leads to remission in 44-89 percent of cases, and this rate improves with second, third, or fourth interventions.2 The addition of vibration does not enhance the effectiveness of this maneuver.32,33




Posterior Canal BPPV

(upbeat nystagmus)

Epley, Foster ½ Somersault, Sermont Liberatory

Anterior Canal BPPV

Dix-Hallpike   (downbeat nystagmus)

Reverse Epley

Horizontal Canal BPPV

Supine Roll Test

Lempert 360 Roll Maneuver


Head Fixed/ Body Turned Test


When performing repositioning maneuvers, movement should be quick in order to generate enough momentum to dislodge displaced canaliths. Clinicians should also recognize these crystals are moving through fluid, which requires a sufficient amount of time to settle into a new position. Clinicians should proactively inform patients that although they may become dizzy during testing or treatment, they should attempt to keep their eyes open and remember the intervention will ultimately help ease their symptoms.

Contraindications to performing repositioning maneuvers include acute cervical spine fracture or instability, recent cervical spine surgery, perilymph fistula, detached retina, unstable carotid artery disease/stenosis, vertebrobasilar insufficiency, stroke, TIA, unstable heart disease, and severe neck disease, such as cervical spondylosis with myelopathy or advanced rheumatoid arthritis.34,35

Dr. Tim Bertelsman is co-founder of the online clinical and business resource Dr. Bertelsman graduated from Logan College of Chiropractic with honors and has been practicing in Belleville, Ill., since 1992. He is a post-graduate instructor for the University of Bridgeport Orthopedic Diplomate program. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as president of its executive board.


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