Benign Positional Vertigo

Benign positional vertigo (BPV)—or simply vertigo—is a disorder of the inner ear. You feel a sudden sensation of movement or spinning when you move your head or hold it in a certain position.

The inner ear is located within your skull and consists of the cochlea, a chamber shaped like a snail shell, where sound is transformed to nerve signals for the brain, and 3 semi-circular canals that function like a gyroscope, relaying information about head position and movement to the brain.

The semicircular canals contain fluid and special sensors that, when disturbed, inform the brain of a change in head position. It is thought that when you have BPV small particles become dislodged within the inner ear and then bounce around when your head moves, triggering faulty signals that your head is still moving even after it stops. This sensation of movement or imbalance when you are not moving is called vertigo, the primary symptom of benign positional vertigo.

It is seldom possible to determine the cause of BPV. It is unclear why small particles become dislodged within the inner ear in the first place. Some possible reasons include the following:

• Head injuries
  
  
• Viral infections (labyrinthitis)
  
  
• Nerve inflammation
  
  
• Inner ear surgery (more common in older people and women)
  
  
• Similar symptoms can be caused by other disorders. A doctor would have to check for them specifically if there is doubt.
  
  
• You may experience the symptoms of BPV if you take too much aspirin or phenytoin (Dilantin) or are intoxicated with alcohol.

Symptoms are the same ones you experience when you spin around in a revolving chair or on an amusement park ride and then suddenly stop.

• Vertigo - A sensation of spinning or movement when you are still
  
  
• Nausea or vomiting - Due to motion sickness caused by the vertigo
  
  
• Nystagmus - Involuntary eye movements or twitches accompanying the vertigo

Call your doctor any time you experience vertigo and nausea for unclear reasons. The doctor will want to ask some questions and either see you in the office or have you go to your hospital’s emergency department.

Go to a hospital if your doctor cannot see you in the office and you have vertigo that is causing repeated vomiting such that you may become dehydrated or cannot take your medications.

• Because driving yourself would be unsafe, you should have a friend or family member take you.
  
  
• Other symptoms that should prompt you to go to an emergency department would be the following:
  
  
  • Headache or ear pain
    
    
  • Fever
    
    
  • Stiff neck
    
    
  • Sensitivity of your eyes to light
    
    
  • Ringing or rushing noises in your ear
    
    
  • Speech difficulties
    
    
  • Weakness or numbness on 1 side of your body or face
    
    
  • Hearing loss
    
    
  • Fainting

The doctor will ask questions that should help determine the cause of your vertigo and whether any tests are necessary.

• No specific laboratory or x-ray tests are available for BPV.
  
  
• The doctor will want to examine your ears and nervous system as part of a physical exam. The doctor also may perform some maneuvers with your head in order to provoke the symptoms and observe any abnormal eye movements that occur.
  
  
• If the doctor suspects a more serious cause of your vertigo other than BPV, additional tests may be performed, such as a CT scan, MRI, or various blood tests.
  
  
• The doctor may consult a neurologist who is a doctor specializing in brain diseases.

|Self-Care at Home|

• Lie down and rest. Take precautions to prevent falls.
  
  
• Do not drive, work at heights, or operate dangerous machinery in case you get an attack of vertigo.
  
  
• Avoid sudden head movements and body position changes, especially looking up.
  
  
• You may try some home therapy exercises that are meant to disburse the inner ear particles that are causing the trouble or desensitize the inner ear nerves that are being stimulated.
  
  
• The following are called the positional exercises of Brandt and Daroff. You will feel vertigo while doing these, but with each repetition, the severity and duration should decrease.
  
  
  1. Sit on the edge of the bed near the middle, with legs hanging down.
     
     
  2. Turn head 45° to right side.
     
     
  3. Quickly lie down on left side, with head still turned, and touch the bed with portion of the head behind the ear.
     
     
  4. Maintain this position and every subsequent position for about 30 seconds.
     
     
  5. Sit up again.
     
     
  6. Quickly lie down to right side after turning head 45° toward the left side.
     
     
  7. Sit up again.
     
     
  8. Do 6-10 repetitions, 3 times per day.

|Medical Treatment|

Some doctors know how to perform certain maneuvers of your head and torso that often relieve or cure the problem without medication.

• These maneuvers are called canalith repositioning procedures, or "the Epley maneuver," and require special knowledge and skill.
  
  
• Their goal is to move the loose particles out of the semicircular canals of the inner ear to where they will no longer cause trouble.
  
  
• After they are performed, you may need to keep your head upright for 24 hours.
  
  
• This may require that you wear a soft neck collar for support and sleep sitting up in a chair for a night.

|Medications|

Several medications, including common motion sickness remedies, may relieve your symptoms of benign positional vertigo (BPV):

• Meclizine (Antivert)
  
  
• Diazepam (Valium)
  
  
• Dimenhydrinate (Dramamine)
  
  
• Promethazine (Phenergan)
  
  
• Scopolamine (Isopto, Scopace)

|Follow-up|

• Avoid activities and situations during which vertigo could be dangerous, such as driving or operating dangerous machinery.
  
  
• Take medication as directed.
  
  
• Drink enough liquids to prevent dehydration, even if you are somewhat nauseated.
  
  
• Avoid alcohol.

|Prevention|

Most cases of BPV do not have a known cause. Therefore, no prevention is possible.

The preventable causes of BPV are head injury and alcohol or medication overdose.

• Always wear a helmet during sporting activities where head injury can occur.
  
  
• Avoid excess consumption of alcohol or aspirin.

|Outlook|

Benign positional vertigo usually clears up on its own within a few weeks or months, even without any specific treatment.

• The Epley maneuver may cure the problem right away.
  
  
• The Brandt/Daroff exercises at home may resolve the problem within a few days.
  
  
• Medications should help control the severity of symptoms otherwise.
  
  
• For some people the disease comes back months or years later.
  
  
• Rarely is BPV a problem that won’t go away. If it continues, a specialist such as an otolaryngologist, head and neck surgeon (ENT), or a neurologist needs to be involved.

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Author: P John Simic, MD, FAAEM, Director of Emergency Medical Services, Director of Emergency Department Approved for Pediatrics, Providence/Saint Joseph Medical Center.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.