Why am I dizzy? Is it BPPV?

Although most people with BPPV can be treated with the Epley maneuver or a home treatment device.  About 5-12% of people cannot be treated.  There are several reasons which should be carefully considered.

1) You do not have BPPV.  There are many kinds of vertigo and only BPPV will respond to the Epley maneuver.  You should always get a proper diagnosis from a physician qualified to diagnose BPPV.  Several serious conditions can cause vertigo as part of their symptom complex and these other conditions should be ruled out.

2) You have BPPV but are doing the maneuver incorrectly.    This is actually the most common reason for treatment failure in people with BPPV.  This may be because you are treating the wrong side or may be because you are performing the maneuver too quickly, with the wrong angles or in the wrong order.  The maneuver is only effective when performed totally correctly.  A BPPV treatment device to assist in the correct performance of the maneuver is available and will visually guide a person through the maneuver.

3) You may have a resistant form of BPPV.  This may be due to the fact that the otoconia, or ear crystals, get stuck in the balance canal or that they get glued to the end of the canal. It is not clear which is true but it seems that some people don’t respond whatever they do.

4) You may have BPPV in both ears.  Due to the nature of BPPV if you have it in one ear it is certainly possible to get it in both ears.  Typically this will present with symptoms on both sides.  A physician can tell you if this is the case.  The Epley maneuver will still work but you will have to do it on both sides.  People often ask if doing one side and then the other will reverse the benefit of the first maneuver. It is not clear that this is true however, we always tell people to treat one side one week then the other side the next week.

With these issues in mind it doesn’t hurt to perform an Epley maneuver in a repeated fashion, it might help but this cannot be guaranteed.    The only caution is that if you have symptoms which do not seem related to BPPV such as weakness or confusion you should seek medical attention.

As we have talked about there are various kinds of “Dizziness”. Sometimes people confuse positional vertigo with motion sickness, because they both happen when in motion.

BPPV is characterized by spinning vertigo when changing into certain positions.  These are typically rolling over in bed, looking up and to the side, or looking under something.  Often it happens on a specific side, either left or right, although some unlucky people have BPPV on both sides.  Many people who have BPPV are afraid to travel in case an attack comes on while away from their own physician.  Devices for the treatment of BPPV are available to take with you when away from home.

Motion sickness is a sensation of “Disequilibrium” or being off balance, or feeling like you are moving when you are not.  It is caused by a disjunction between what you see and what you feel, or between what you feel and what your ear is telling you.  A good example of this is when the car beside you at a traffic light rolls backward and it makes you feel like you are rolling into the intersection (your eyes tell you that you are moving but your body and balance organ say you are still).  Not only is this a bit anxiety provoking but it often causes an uncomfortable sickness feeling of disequilibrium.  Another good example is the familiar sensation of reading in a moving car.  Your eyes tell you that you are sitting still, since you are looking at a book, but your ear and body tell you that you are moving.  It is this disjunction that is the culprit in motion sickness.

There is also an under-diagnosed but interesting phenomenon called “Mal de Debarquement” syndrome.  Everyone has heard of sea-sickness (a type of motion sickness) but this happens when you get off the boat.  Typically the individual has not had sea-sickness and is the envy of everyone else until they step back onto dry land. Then they still feel like they are on a boat.  In some cases this is temporary but in others it is permanent.  These people may be seen swaying down the streets as if on board a boat in rough seas.  It is a difficult and very frustrating problem for which there is currently no cure.

In general, traveling with vertigo can be scary.  Tips on traveling can be found at http://jetseventravel.com.  In order to overcome vertigo and get back to living your life, learn as much as you can about your own condition and travel with adequate preparation.  For example, if you get motion sick bring anti-nauseant medication (Gravol/Antivert/Dramamine), if you have Menieres disease, Serc can be useful, and if you have BPPV learn the treatment maneuver or take a self treatment device with you.

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.