Why am I dizzy? Is it BPPV?

People often ask, “I have tried the Epley Maneuver, it didn’t work, should I keep trying?”

In general terms, it may take several attempts to fully treat BPPV and most people can expect to have some recurrences.  We suggest that you need only perform the maneuver when you have an attack.  If you are not having symptoms then you don’t need to to do the maneuver although it may prevent recurrences.  It is always important to seek the advice of your own doctor to obtain a diagnosis and to monitor your condition.

With that said here are several important questions to ask yourself about failed BPPV treatment.

1. Do you have BPPV?
   1. To achieve success with the Epley Maneuver or home treatment for BPPV you must be sure you have a correct diagnosis. These maneuvers do not work if you do not have BPPV.  There are many other types of dizziness, although BPPV is the most common.
   2. Posterior BPPV?
      1. There are actually a number of sub-types of BPPV.  Posterior canal BPPV (P-BPPV) is by far the most common.  The Epley maneuver treats P-BPPV but not the others.
2. Did you do the maneuver correctly?
   1. Although the treatment maneuvers for BPPV are very effective it is not yet clear how incorrectly you can perform them and still have success.  The major reason for home treatment failure is an incorrectly performed maneuver . Home BPPV treatment devices are designed to minimized this problem.  Careful attention to detail in the maneuver as well as ensuring the correct angles, side and duration will improve success.  The most common mistake,..not putting you head back far enough (it can be too far though).
3. Do you have bilateral BPPV?
   1. A small percentage of people will have BPPV on both sides and so after successful treatment on one side will still have symptoms.  This can be confusing.  We recommend that people treat one side daily for one week then switch to the other side.
4. Do you have recurrent BPPV?
   1. BPPV treatment does not cure the problem it only removes the stimulus temporarily so as many as 60% of people will have symptoms more than once.   Some people have highly recurrent BPPV so after they successfully treat one episode it can come back in a matter of days and make them think they failed in their maneuver.  Daily maneuvers may control these problems.  In rare cases of very symptomatic and resistant BPPV surgery can be performed to block of the balance canal which causes BPPV.
5. Are you ever going to respond?
   1. Do you have something else as well?
      1. BPPV can be found along with any other disease which causes inner ear damage.  Conditions like Menieres, head trauma, or inner ear infections may causes BPPV.  As such it can be confusing as to which condition is causing the vertigo.  Generally these symptoms can be sorted out by a skilled ear doctor.  You might need help with this one.
   2. Do you have resistant BPPV?
      1. About 5% of people have BPPV which is resistant to maneuvers.  This may be because the disease causing crystals are too large to come out of the posterior canal or that they are stuck to the inner ear somewhere.   Regardless the Epley maneuver does not work for these people.  Again in certain circumstances surgery may be indicated.

One of the key findings in BPPV is the presence of nystagmus.  This is the medical term for the involuntary eye movement which occurs when the body changes position.  It is characterized by alternating smooth pursuit eye movements  in one direction and saccadic (quick catch up) movements in the other direction.  This is a useful phenomonon as it allows people to keep things in focus even moving and turning your head, without it things would be fuzzy when you nod your head.   Nystagmus itself is normal, however there are pathologic forms of nystagmus.

In BPPV there is a phenomenon known as positional nystagmus.  When a person with BPPV is in a position which causes them dizziness their eyes exhibit a characteristic motion, called nystagmus. What happens is the inner ear perceives that body is moving (this is the vertigo associated with BPPV) and tells the eyes to move to keep up. The only problem is that the body is not moving, and having your eyes move involuntarily while you are still can be quite disconcerting.

You can see a video of Nystagmus related to BPPV on Youtube.

The maneuver in the video is called “Dix-Hallpike Maneuver” and it elicits the symptoms of BPPV and, more specifically, the nystagmus.  There are many types of nystagmus but there are a few qualities of which make the diagnosis of BPPV easier.

Nystagmus associated with BPPV has to have the below characteristics:

1. Positional in onset (only in a head hanging position will it come on)
2. Short lived (lasts only a few seconds to minutes)
3. Geotropic – the top of the eye beats (fast phase) toward the side on which your head is hanging
4. Rotatory and small upbeat component – the eye rotates or twists, as above, and has a slight fast phase up motion
5. Fatigable – repeating the maneuver again and again will stop it from happening temporarily
6. Latent onset – there is a slight lag phase of a few seconds before the nystagmus starts when in the head hanging position.

So why do you get nystagmus with BPPV?  Well that can be the subject of another post.

It is difficult to discuss dizziness because it means different things to different people.  There are three main terms in use by physicians which describe what we all refer to as “dizziness”

1. Disequilibrium

   Disequilibrium is the sensation of being off balance, much like when getting off a boat, and is sometimes characterized by falls in a specific direction. This condition is not often associated with nausea or vomiting or vertigo.

2. Pre-syncope

   Pre-syncope (literally near fainting) or lightheadedness, like when standing up too quickly. Pre-syncope is often related to low blood pressure.  If loss of consciousness occurs in this situation, it is termed syncope (fainting).

3. Vertigo

   Vertigo is a specific medical term used to describe the sensation of spinning or having the room spin about you. Many people find vertigo very disturbing and often report associated nausea and vomiting.

   If the vertigo arises from the inner ear, it is severe and has associated nausea and vomiting. One common cause of otologic vertigo is benign paroxysmal positional vertigo (BPPV). Alternate causes of vertigo originating from the inner ear include Ménière’s disease, superior canal dehiscence syndrome, and labyrinthitis.

If vertigo arises from the balance centers of the brain, it is milder, and has accompanying neurologic deficits, such as slurred speech, double vision or nystagmus. Alternately, brain pathology can cause a sensation of disequilibrium which is an off-balance sensation.

Being able to identify and discuss these different symptoms will help you and your physician narrow down your problem and possibly come up with a treatment for you vertigo.

Someone recently asked me about their elderly mother doing maneuvers for the home treatment of BPPV.  Since she is elderly she apparently had difficulty moving her head back far enough to complete the standard maneuver.    

The good news about home treatment is that the Epley Maneuver can be conducted at home with some help.  This is much more effective than previous maneuvers such as the Brant Daroff exercises.  The hope is that fewer maneuvers need be conducted to successfully treat the condition. 

However, some people should not perform the maneuver.  This includes, amongst others, people with neck injury, limitation of their neck range of motion, a history of stroke/TIA due to vertebro-basilar insufficiency and other health conditions as advised by their doctor.

Certainly home maneuvers are effective but they should not be conducted alone or by people who have difficulty or other medical conditions which put them at risk. Home maneuvers should always be conducted on the floor to prevent falls and in the presence of another person for assistance if needed.  When in doubt see your doctor.

I was recently asked: “Has any BPPV patient managed to make their condition worse with a bungled treatment?”

The answer is not particularly straight forward.  Any treatment of BPPV has the potential to convert to something called Horizontal canal BPPV. The most common type of BPPV is Posterior canal BPPV. 

The estimated rate of this complication of treatment of BPPV is about 5%. You run this risk every time you roll over in bed but in particular during a repositioning maneuver. The good news is that horizontal BPPV, while more intense (if you can believe that) it is often short lived and goes away by itself in nearly all cases.

Home treatment of BPPV has no higher risk of this conversion than office maneuvers. The only benefit of the in office treatment is that there is someone there to comfort you.  I also suggest that you never do the maneuver alone even if you are doing it at home. You just never know if you need help if you vomit or feel nauseous.