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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Most common vertigo cause — displaced otoconia in posterior semicircular canal (90%)
- Brief episodes (<1 min) triggered by rolling in bed, looking up, bending forward
- Dix-Hallpike: DIAGNOSTIC — torsional upbeating nystagmus with 2–5 sec latency and fatigability
- Epley manoeuvre: CURATIVE — relocates otoconia. >80% effective
- Do NOT prescribe vestibular suppressants long-term — they delay compensation
- Red flags: no latency, no fatigability, vertical nystagmus → central cause (stroke)
Overview
BPPV is caused by displacement of otoconia (calcium carbonate crystals) from the utricle into a semicircular canal (usually posterior, ~90%). Head movement causes abnormal endolymph flow and cupula stimulation, producing brief intense vertigo and characteristic nystagmus. Diagnosis is clinical using Dix-Hallpike. Epley manoeuvre is highly effective.
Epidemiology
Lifetime prevalence ~2.4%. More common in women (2:1), peak 50–70 years. Predisposing: head trauma, bed rest, vestibular neuritis. Recurrence ~15–20%/year.
Clinical Features
Symptoms
Brief intense rotational vertigo <1 min, triggered by position changes
Nausea
NO hearing loss, NO tinnitus
Persistent vertigo lasting hours/days + neurological symptoms → central cause
Signs
Positive Dix-Hallpike: torsional upbeating nystagmus, 2–5 sec latency, <1 min, fatigues
Normal neurology and hearing
No latency, no fatigability, direction-changing nystagmus → central
Investigations
First-line
Dix-Hallpike testDiagnostic: supine with head turned 45° and neck extended. Positive = torsional nystagmus with latency and fatigability
Supine roll testFor lateral canal BPPV if Dix-Hallpike negative
Second-line
AudiometryIf hearing loss — exclude other diagnoses
Specialist
MRI brainONLY if atypical: no latency/fatigability, direction-changing nystagmus, focal neurology
Management
NICE CKS and AAO-HNS 20171
Epley manoeuvre
- Definitive treatment for posterior canal BPPV
- 4 head position changes moving otoconia back to utricle
- >80% success single treatment, >95% with repeats
- No post-procedural restrictions needed
2
If Epley fails
- Repeat up to 3 times
- Brandt-Daroff home exercises as adjunct
- Horizontal canal: BBQ roll or Gufoni manoeuvre
3
What NOT to do
- No long-term vestibular suppressants (prochlorperazine) — delays compensation
- No CT/MRI for typical BPPV
4
Follow-up
- Review 1–4 weeks, repeat Dix-Hallpike
- If persistent → audiovestibular referral
- Recurrence 15–20%/yr — teach self-Epley
Complications
- Falls: Especially in elderly
- Anxiety/kinetophobia
- Canal conversion: Otoconia displaced to different canal during Epley
UKMLA Exam Tips
- 1BPPV: brief (<1 min), positional, positive Dix-Hallpike, NO hearing loss
- 2Peripheral nystagmus: LATENCY, FATIGABILITY, torsional/upbeating. Central: no latency, no fatigue, direction-changing
- 3Treatment: Epley (NOT medication). Prochlorperazine delays recovery
- 4BPPV = seconds. Ménière's = hours. Vestibular neuritis = days
- 5Dix-Hallpike tests POSTERIOR canal. Supine roll = HORIZONTAL canal
practicetest your knowledge on BPPVApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — ENT and beyond.
open q-bank regional clinical guidance
Benign Paroxysmal Positional Vertigo: guidance by region
Recommendations, thresholds and pathways can differ. Open the page written for the jurisdiction you need.