What is BPPV?
BPPV (Benign Paroxysmal Positional Vertigo) is a common inner ear disorder that causes brief spells of vertigo (spinning sensation) triggered by a change in head position. For example, lying back or rolling over in bed, getting up from bed, looking up or down results in brief, 10-15 seconds of vertigo and usually no dizziness any other time. BPPV is caused by“crystals” normally present in one part of the inner ear, but become detached and displaced into another part of the inner ear where they cause vertigo with changes in head position. However, there are many patients diagnosed with BPPV who do not fit this description of symptoms or have a different cause of positional vertigo, yet are often diagnosed and unsuccessfully treated as though they had BPPV.
Why is BPPV Over-diagnosed?
BPPV has gained popularity as a diagnosis because it is a benign condition that causes vertigo and is readily diagnosed and immediately cured by a skilled healthcare provider. Patients often joke about “having a few loose rocks” in their head. BPPV is a common condition, but there are many more people diagnosed with BPPV than actually have BPPV.
How is BPPV Treated?
BPPV is treated by a “crystal repositioning maneuver” (CRM), which is designed to move the “crystals” by gravity back to where they originated, where they may be dissolved. The type of CRM utilized depends on the type of BPPV. For example, one form of BPPV is treated with a modified Epley or a Semont maneuver and another type with a Lempert roll. There is also a type of BPPV where the “crystals” are actually stuck to a membrane in the inner ear and is treated with a headshake of Gufoni maneuver. BPPV is no longer treated by the old fashioned Brandt-Daroff or Cawthorne-Cooksey exercises, or with medications, such as meclizine (Antivert). We are actually able to cure BPPV in one visit over 90% of the time with the appropriate CRM. Unfortunately, we see many patients incorrectly diagnosed with BPPV undergoing a modified Epley maneuver dozens of times unsuccessfully.
What else causes positional vertigo if it’s not BPPV?
Because migraine is the most common cause of dizziness/vertigo and can cause positional symptoms, the most common correct diagnosis in those mis-diagnosed with BPPV, is vestibular migraine. Other conditions which may cause positional dizziness include inner ear nerve weakness, blood pressure changes and even brain tumors. Obviously, it is very important to be certain of the cause of vertigo, as we don’t want to ineffectively treat for a condition that isn’t present and we don’t want to miss a more sinister cause.
In a 2011 survey by the Vestibular Disorders Association (VEDA), it was determined that those suffering from dizziness (the “dizzy” patient) were on average seen by 4-5 doctors before receiving the correct diagnosis. As is the case with any medical condition, without the correct diagnosis, the most appropriate treatment cannot be administered.
Symptoms of dizziness are typically subjective and an accurate diagnosis at first may not be straight forward. Many patients suffering from dizziness typically see several doctors and undergo multiple tests while accumulating large medical bills and no answers. The time “dizzy” patients spend in this process can be months to years and may result in painful fall-related injuries while seeking help from various healthcare practitioners.
“Dizzy” patients may initially be seen by their primary care physician or go to an urgent care facility or emergency room, then, as the potential underlying cause for dizziness can be diverse, referred to ENT (Ear, Nose and Throat – aka Otolaryngologist), a neurologist and/or cardiologist. Studies reveal that many undergo brain or sinus CT and/or MRI scans, carotid doppler studies, EEG, EKG, echocardiogram, tilt table testing, and blood tests, all of which have low yield in arriving at the correct diagnosis for most “dizzy” patients. Vestibular suppressant medications, such as meclizine, diazepam or promethazine, typically offer little relief and the majority of “dizzy” patients do not significantly benefit from PT (physical therapy).
The knowledge and technology we have available today in the diagnosis and treatment of the “dizzy” patient has advanced significantly and is different than what would have been considered standard of care just 20 years ago. At the initial visit to a physician experienced in vestibular disorders, the “dizzy”patient will be given the most likely diagnosis and a short list of differential diagnoses. Vestibular function testing and an audiogram (hearing test) are generally the most valuable tests to obtain for the “dizzy” patient, and will help confirm or refute the diagnosis suspected by clinical information obtained in the history and physical exam.
Arriving at the correct diagnosis is vitally important because effective treatment of “dizziness” depends on the diagnosis. One cause of dizziness requires a specific sequence of head movements which can result in an instant cure, another cause is treated by reducing dietary sodium and/or a diuretic medication, while the most common cause of dizziness improves or resolves with a migraine-preventative medication, and other causes benefit from a specialized form of PT (physical therapy) known as vestibular rehabilitation therapy.
Especially in this age of high deductible health insurance plans, patients are seeking the most expedient and accurate diagnoses and the most effective treatment in a cost-effective manner. With the advanced diagnostic and treatment capabilities available today, “dizzy” patients should no longer have to see 4-5 doctorsbefore receiving the correct diagnosis.
There are many causes of dizziness and vertigo that we are now able to recognize and treat. One common type of vertigo, known as BPPV (Benign Paroxysmal Positional Vertigo), aka “the crystal problem”, can be cured with a procedure known as a CRM (Canalith Repositioning Maneuver). Symptoms of BPPVinclude brief vertigo, lasting 10-15 seconds, brought on by lying back or getting up from bed, rolling over in bed, looking up or down. It is important to identify which type of BPPV is present, as we now know multiple types of BPPV exist. With the appropriate CRM, success in treating BPPV is nearly 100%. We should no longer be using medications, such as meclizine, or habituation exercises (Brandt-Daroff or Cawthorne-Cooksey) to treat BPPV. Click here to view a video of the most common type of BPPV, posterior semicircular canal BPPV.
Unfortunately, BPPV has become a well known entity over the years and is now over diagnosed. Treatment with a CRM in someone who does not have BPPV will not work. So, if you have been told that you have BPPV, but your vertigo symptoms did not resolve after a correctly performed CRM, then BPPV may not be the correct diagnosis.