Benign Paroxysmal Positional Vertigo — Diagnosis and Epley Manoeuvre

Definition and mechanism. BPPV is the commonest cause of recurrent vertigo in older adults — brief episodic vertigo provoked by a change in head position relative to gravity, caused by displaced otoconia from the utricular macula entering a semicircular canal. Canalolithiasis (free-floating debris) is commoner than cupulolithiasis (debris adherent to the cupula). The posterior canal is involved in 85–90%, the horizontal canal in 5–15%, and the anterior canal rarely.

Clinical features. Sudden spinning vertigo lasting less than one minute, triggered by turning over in bed, lying down, sitting up, bending forward or looking up (“top-shelf vertigo”), with nausea and residual unsteadiness between attacks. There is no hearing loss, tinnitus or neurological deficit. In older people it more often presents as falls, unsteadiness and fear of falling than as classical rotatory vertigo.

Diagnosis — the Dix–Hallpike manoeuvre (posterior canal). The patient sits upright, the head is rotated 45° towards the ear being tested, and the patient is laid rapidly supine with the head extended 20–30° below the horizontal. A positive test shows, after a latency of 1–5 seconds, up-beating torsional (geotropic) nystagmus lasting less than 60 seconds, which reverses on sitting up and fatigues on repetition. The supine roll (Pagnini–McClure) test diagnoses horizontal-canal BPPV.

Red flags for central positional vertigo. Nystagmus with no latency, no fatigability, that is purely vertical or down-beating or direction-changing; disproportionate truncal ataxia; other brainstem or cerebellar signs; new headache; or vertigo unresponsive to repositioning. These require urgent MRI to exclude posterior fossa stroke or tumour.

The Epley (canalith repositioning) manoeuvre — four steps, each held about 30 seconds or until nystagmus stops. (a) Dix–Hallpike position with the head turned 45° to the affected side; (b) rotate the head 90° to the opposite side while supine; (c) roll the patient onto that shoulder and turn the head a further 90° so the nose points to the floor; (d) sit the patient upright with the chin tucked. Success is 80–90% in one or two sessions. Alternatives: Semont liberatory manoeuvre; Lempert barbecue roll for horizontal canal; Brandt–Daroff exercises for home use.

Precautions and drug therapy in the elderly. Before repositioning, check for cervical spondylosis, severe kyphosis, vertebrobasilar insufficiency, carotid disease, retinal detachment or recent neck surgery, and modify with a shoulder roll and reduced neck extension. Vestibular sedatives — betahistine, prochlorperazine, cinnarizine — do not treat BPPV; they delay central compensation and cause drowsiness, falls and drug-induced parkinsonism, so they should not be continued beyond 24–48 hours. Recurrence occurs in 15–50%.

Vitamin D supplementation reduces BPPV recurrence. Randomised and meta-analytic evidence from 2024– 2025 — including a randomised controlled trial in older adults (Otolaryngol Head Neck Surg 2025), a placebo-controlled RCT (Laryngoscope Investig Otolaryngol 2024) and a systematic review (Nutrients 2024) — shows that vitamin D supplementation significantly lowers the recurrence rate of BPPV in patients with serum 25(OH)D below 20 ng/mL. Recognised recurrence risk factors are advanced age, female sex, hypertension, diabetes, hyperlipidaemia, osteoporosis and vitamin D deficiency. Therefore check vitamin D in recurrent BPPV and replace it — a cheap intervention that simultaneously addresses osteoporosis and falls risk.