How can I differentiate between BPPV and other causes of vertigo in my patients?

To differentiate benign paroxysmal positional vertigo (BPPV) from other causes of vertigo in your patients, focus on the characteristic clinical features and diagnostic manoeuvres:

• BPPV typically presents with transient episodes of rotational vertigo triggered by specific head movements or changes in position, such as lying down or turning over in bed.
• Perform the Dix-Hallpike manoeuvre (or Hallpike manoeuvre) to diagnose BPPV; a positive test elicits characteristic nystagmus and vertigo lasting less than a minute.
• If the Hallpike manoeuvre is positive, BPPV is likely; if negative or if atypical symptoms/signs are present (e.g., hearing loss, tinnitus, neurological signs), consider other diagnoses and refer accordingly.
• Other causes of vertigo, such as vestibular migraine, stroke, or vestibular neuritis, often have different clinical features: vestibular migraine involves recurrent dizziness lasting 5 minutes to 72 hours with a history of migraine; stroke may present with sudden-onset vertigo plus focal neurological deficits; vestibular neuritis presents with acute vestibular syndrome including vertigo, nausea, vomiting, and gait unsteadiness.
• Use the HINTS test (head impulse, nystagmus, test of skew) in acute vestibular syndrome to help differentiate central causes (e.g., stroke) from peripheral causes like vestibular neuritis.
• Refer patients urgently if there are atypical features, neurological deficits, or if BPPV treatment manoeuvres fail after two attempts, to exclude alternative diagnoses.

Summary: Use positional testing (Hallpike manoeuvre) to identify BPPV, observe the pattern and duration of vertigo, assess for neurological signs, and consider other diagnoses if features are atypical or treatment fails. Refer as needed for specialist assessment.

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