Benign Paroxysmal Positional Vertigo

Abstract

clinical practiceT h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 370;12 nejm.org march 20, 2014 An audio version of this article is available at NEJM.orgA 58-year-old woman seeks care from her primary physician after the occurrence of sudden vertigo and imbalance with nausea and vomiting, which began that morning when she got out of bed. The vertigo lasted less than a minute but recurred when she lay back down in bed, rolled over in bed, or got up again. She reports no tinnitus or hearing loss. How should this patient be evaluated and treated?The Clinic a l ProblemBenign paroxysmal positional vertigo (BPPV) is by far the most common type of vertigo, with a reported prevalence between 10.7 and 64.0 cases per 100,000 population and a lifetime prevalence of 2.4%. 1,2 The condition is characterized by brief spinning sensations, usually lasting less than 1 minute, which are generally induced by a change in head position with respect to gravity. 3,4 Vertigo typically develops when a patient gets in or out of bed, rolls over in bed, tilts the head back, or bends forward. 3 Even though patients with BPPV occasionally report persistent dizziness and imbalance, a careful history taking almost always reveals that their symptoms are worse with changes in head position. 4 Many patients also have nausea, sometimes with vomiting. Attacks of BPPV usually do not have a known cause, although cases may be associated with head trauma, a prolonged recumbent position (e.g., at a dentist's office or hair salon), or various disorders of the inner ear. 3 Spontaneous remissions and recurrences are frequent; the annual rate of recurrence is approximately 15%. 5 Patients with BPPV are at increased risk for falls and impairment in the performance of daily activities. 6 The prevalence of idiopathic BPPV is increased among elderly persons and among women, with peak onset between 50 and 60 years of age and a female-to-male ratio of 2:1 to 3:1. 2,3 BPPV has also been reported to be associated with osteopenia or osteoporosis and with decreased serum levels of vitamin D -associations that are not explained by age or sex. 7,8 The fundamental pathophysiological process in BPPV involves dislodged otoconia from the macula of the utricular otolith that enter the semicircular canals. When there is a change in the static position of the head with respect to gravity, the otolithic debris moves to a new position within the semicircular canals, leading to a false sense of rotation. BPPV usually arises from the posterior semicircular canal, which is the most gravity-dependent canal; this type of BPPV accounts for 60 to 90% of all cases. 4 However, the proportion of patients with BPPV that involves the horizontal semicircular canal may have been underestimated, since involvement at this site is more likely to remit spontaneously than involvement in the posterior semicircular canal. 9 BPPV rarely involves the anterior semicircular canal, probably because of its uppermost position in the labyrinth, where otolithic debris is unlikely to become tra...

Vertigo in childhood: A retrospective series of 100 children

“…Triggering by head movements suggest BPPV. 36 Focal neurological deficit or history of head trauma brings up the need for imaging. Clinical examination should include measurement of blood pressure and electrocardiography (ECG) to rule out cardiovascular disease such as arrhythmia or long QT syndrome.…”

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

“…253 Also, the addition of an antihistamine to canal repositioning maneuvers demonstrated no change in the Dizziness Handicap Inventory score. 14 However, more recent studies have shown that there may be some pharmacologic benefit in select patients. In 1 randomized study, the addition of a benzodiazepine to canal repositioning maneuvers significantly decreased the functional and emotional scores of the Dizziness Handicap Inventory but did not affect the physical score when compared with patients who were treated with canal repositioning maneuvers alone, thereby suggesting a role in treating psychological anxiety secondary to BPPV.…”

Clinical Utility of Ocular Vestibular-Evoked Myogenic Potentials (oVEMPs)

“…Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of rotational vertigo, typically triggered by a change in head position with respect to gravity [58]. The vertigo is caused by detached otoconia, which most often enter the posterior semicircular canal.…”