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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- BPPV causes brief episodes of vertigo triggered by head position changes, usually lasting seconds to less than 1 minute
- Posterior canal BPPV is diagnosed by Dix-Hallpike causing vertigo and torsional upbeating nystagmus
- Treatment is canalith repositioning, usually the Epley maneuver; medications are not definitive therapy
- Routine imaging, vestibular testing, and vestibular suppressants are not recommended for typical BPPV
- Persistent neurologic deficits, vertical nystagmus, severe gait ataxia, or new headache suggests central vertigo/stroke
Overview
BPPV is the most common peripheral vestibular disorder. It results from otoconia displaced from the utricle into a semicircular canal, most commonly the posterior canal. Head movements such as rolling in bed, looking up, bending over, or sitting up trigger abnormal endolymph movement and transient vertigo. The patient is well between attacks. The AAO-HNS guideline emphasizes accurate bedside diagnosis and treatment with repositioning maneuvers while avoiding unnecessary imaging and vestibular suppressant medications.
Epidemiology
BPPV is common in adults, especially older adults, and is more frequent in women. Risk factors include age, head trauma, vestibular neuritis, migraine, prolonged bed rest, and osteoporosis. It can recur after successful treatment. Although benign, it increases fall risk and can significantly impair function.
Clinical Features
Symptoms
Brief spinning vertigo triggered by rolling over in bed, looking up, bending forward, or rapid head movement
Episodes last seconds, typically <1 minute, with nausea possible
No persistent hearing loss, tinnitus, focal neurologic symptoms, or continuous vertigo in typical BPPV
New focal weakness, diplopia, dysarthria, severe truncal ataxia, or inability to walk
New severe headache or neck pain with vertigo
Continuous vertigo for days suggests vestibular neuritis, labyrinthitis, or central cause rather than BPPV
Signs
Dix-Hallpike: latency followed by transient torsional upbeating nystagmus in posterior canal BPPV
Nystagmus fatigues with repeated testing in peripheral BPPV
Horizontal canal BPPV may show direction-changing horizontal nystagmus on supine roll test
Normal neurologic examination and gait between episodes
Pure vertical nystagmus, direction-changing gaze-evoked nystagmus, or skew deviation suggests central lesion
Investigations
First-line
Dix-Hallpike maneuverBest diagnostic test for posterior canal BPPV. Positive test reproduces vertigo with characteristic torsional upbeating nystagmus
Supine roll testUse if history suggests BPPV but Dix-Hallpike is negative, especially for horizontal canal BPPV
Second-line
No routine imagingDo not order CT/MRI for typical BPPV with no neurologic red flags
No routine vestibular testingAudiometry/vestibular lab testing is unnecessary for classic BPPV
Specialist
MRI brain/internal auditory canalsIf central signs, atypical nystagmus, severe headache, stroke risk, new neurologic deficits, or failure to fit BPPV pattern
Vestibular specialist/ENT/PT referralRefractory, recurrent, atypical, or fall-risk patients; vestibular rehabilitation may help
1
Canalith repositioning
- Posterior canal BPPV: Epley maneuver is first-line and often rapidly effective
- Semont maneuver is an alternative
- Horizontal canal BPPV: barbecue roll/Lempert maneuver or Gufoni maneuver depending on nystagmus pattern
2
What to avoid
- Do not routinely treat BPPV with vestibular suppressants such as meclizine or benzodiazepines
- Do not restrict activity for prolonged periods after repositioning; routine post-maneuver restrictions are not necessary
- Do not obtain routine imaging when presentation is classic
3
Follow-up and recurrence
- Reassess within about 1 month to document resolution or persistent symptoms
- Teach recurrence recognition; repeat repositioning maneuvers if symptoms recur
- Address fall risk in older adults
Complications
- Falls: Major concern in older adults with positional vertigo
- Recurrence: BPPV frequently recurs and may need repeated maneuvers
- Functional limitation: Avoidance of head movement can impair mobility and sleep
- Missed central vertigo: Atypical nystagmus or neurologic signs require stroke/posterior fossa evaluation
USMLE Step 2 CK Exam Tips
- 1Vertigo lasting seconds and triggered by rolling in bed = BPPV
- 2Dix-Hallpike is the diagnostic test for posterior canal BPPV
- 3Epley maneuver is the treatment, not meclizine
- 4BPPV has no hearing loss; hearing symptoms suggest Meniere disease or labyrinthitis
- 5Vertical nystagmus or focal neurologic deficit = central vertigo until proven otherwise
- 6Routine CT/MRI is wrong for classic BPPV
- 7Vestibular suppressants may worsen compensation and are not definitive BPPV therapy
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