Clinical features

• symptoms are precipitated by a change of position of the head with respect to gravity (1)
• the most prominent symptom of BPPV is brief episodes (<1 min) of vertigo which occur during specific movements of the head (2):
  • vertigo that occurs in bed when a patient rolls into a lateral position
  • vertigo when the patient is gazing upward - e.g., to place an object on a shelf
  • vertigo when bending forward - e.g., to tie the shoes
• typically, each episode of vertigo lasts only 10 to 20 seconds although the duration may be overestimated by several minutes (3)
• these attacks occur in spells and a patient may experience several attacks a week or during the course of 1 day (3)
• nausea is common but vomiting is rare.
  • the initial onset of vertigo is often associated with nausea, with or without vomiting.
• lightheadedness and imbalance also may be associated (1)
• presence of hearing loss, tinnitus, or feeling of fullness of the ears indicates another diagnosis (4)
• it is usually a self-limiting disorder that may be present for several weeks or even years
• remissions and recurrences occur unpredictably
• the diagnosis of posterior BPPV is confirmed by performing the Hallpike manoeuvre (5)
  • a positive test may be seen in around 50% of patients at presentation (4)
  • helps in confirming the diagnosis of BPPV, localising the affected side and to demonstrate canalith mobility (6)
• lateral canal BPPV (also known as horizontal canal BPPV) can be diagnosed by the supine roll test.
  • patients head is rotated 90 degrees to each side on supine position and the eyes are observed for nystagmus

Reference:

• (1) Benign paroxysmal positional vertigo.American Hearing Research Foundation 2006
• (2) Bronstein A. Benign Paroxysmal Positional Vertigo (BPPV):Diagnosis and Physical Treatment. ACNR 2005;5(3)
• (3) Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;169(7):681-93
• (4) Hanley K, O'Dowd T, Considine N. A systematic review of vertigo in primary care. Br J Gen Pract. 2001;51(469):666-71
• (5) Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999;341:1590
• (6) Kuo CH, Pang L, Chang R. Vertigo - part 2 - management in general practice. Aust Fam Physician. 2008;37(6):409-13