Gordon H. Sun, MD, MS


April 20, 2017

Diagnosing BPPV

The AAO-HNSF clinical practice guideline on BPPV states that the diagnosis of posterior canal BPPV typically requires only two elements: patient-reported history of vertigo provoked by changes in head position relative to gravity, and characteristic nystagmus and vertigo triggered by the Dix-Hallpike maneuver.[1] Vertigo is usually described as severe, sporadic, provoked by otherwise innocuous activities, and lasting 1 minute or less. Up to one half of patients with BPPV may manifest imbalance between episodes of BPPV.[4] Patients often become anxious about future BPPV episodes and often attempt to avoid the head movements that trigger the vertigo.[6]

The Dix-Hallpike maneuver remains the gold standard for diagnosing posterior canal BPPV. A positive test requires that vertigo associated with torsional (rotatory) and up-beating (toward the forehead) nystagmus be provoked, with a latency period between completion of the maneuver and onset of symptoms. Finally, the provoked vertigo and nystagmus should increase in intensity and resolve within 60 seconds of onset of nystagmus.

Patients with posterior canal BPPV also demonstrate fatiguable nystagmus with repeated attempts of the Dix-Hallpike maneuver.[10] However, doing so is discouraged by many experts, owing to the possibility of interfering with bedside treatment of BPPV.[1,11]

Lateral (horizontal) canal BPPV is in the differential diagnosis for patients with a history consistent with BPPV but a negative Dix-Hallpike test. The supine head roll test (also known as the Pagnini-Lempert or Pagnini-McClure roll test) can be used to evoke vertigo and nystagmus in lateral canal BPPV.[12,13] In these cases, the nystagmus is typically horizontal, either geotropic (beating toward the ground) or apogeotropic (beating away from the ground). In patients who meet diagnostic criteria for BPPV but lack other symptoms and/or signs inconsistent with BPPV, the AAO-HNSF guideline for BPPV recommends against both radiographic and vestibular testing.[1]

Case 3: Observe or Reposition?

A 59-year-old writer was seen by his internist for sporadic vertigo and disequilibrium. He first noticed the symptoms after he tripped and hit his head on his concrete driveway several weeks ago. He visited an emergency department and underwent head CT, which was negative for any significant pathology. The patient reported receiving a prescription for "some pills" to control the dizziness, but he has avoided using them because he does not like taking medication.

The patient is otherwise healthy, and physical examination was unremarkable other than a positive Dix-Hallpike maneuver with the patient facing left. The clinician was confident in her diagnosis of posterior canal BPPV. The patient inquired about potential treatment options that would not include medications.


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