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Benign paroxysmal positional vertigo — CCFP MCQ

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EasyChronic disease managementBenign paroxysmal positional vertigoCCFP

A 48-year-old woman experiences recurrent brief episodes of vertigo triggered by rolling in bed. Each episode lasts less than one minute. Neurological examination is normal. Dix-Hallpike testing on the right produces torsional nystagmus and reproduces her symptoms. What is the most likely diagnosis?

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Correct answer: B — Benign paroxysmal positional vertigo

The diagnosis is benign paroxysmal positional vertigo (BPPV). The Dix-Hallpike test is the gold standard for diagnosing posterior canal BPPV, the most common form. A positive test—manifesting as torsional (rotatory) nystagmus that reproduces vertigo—confirms the diagnosis in a patient with the typical presentation: brief episodes (seconds to <1 minute) triggered by specific head positions such as rolling in bed. The normal neurological examination excludes central causes. Vestibular migraine causes longer-duration vertigo with migraines; vestibular neuritis presents with continuous vertigo and spontaneous nystagmus, not episodic; Menière disease involves hearing loss, tinnitus, and hours-long episodes; posterior circulation TIA would show focal neurological signs. The combination of positional trigger, short duration, and positive Dix-Hallpike with characteristic nystagmus is pathognomonic for BPPV.

Reference: Canadian Medical Association Journal. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;169(7):681–693. Reprinted Feb 2020 with clinical update: 'Clinical diagnosis of benign paroxysmal positional vertigo and vestibular neuritis.' CMAJ. 2020;192(8):E182. https://www.cmaj.ca/content/192/8/e182