One morning in early September, a bit late for a semi-commitment, I jumped out of bed — something I do not often do. Like most of us I headed to the bathroom first. However, by the time I got there I noticed an uneasy and unusual feeling. Within 5 seconds it was worse. Incredible dizziness and nausea had come over me. Well, I knew I wasn’t pregnant! Instead, for the second time in my life, I was experiencing an attack not at all uncommon to those over the 50-year mark. It quickly became obvious I wasn’t going anywhere.
While not always a wise thing to self-diagnosis, I was fairly confident that it was BPPV – Benign Paroxysmal Positional Vertigo. BPPV is also sometimes abbreviated as BPV, leaving out the ‘paroxysmal.’ First, let’s break down the fancy lingo of B.P.P.V.
‘Benign’ (like in a cancer diagnosis) translates to “relax, it’s okay.” The condition is harmless in terms of life threating – generally not dangerous or serious. However, Marvin (fictitious name) came to see me when I was in practice after he had undergone miserable attacks for over a week. He responded to my explanatory summary with understandable annoyance “well, it won’t be benign if I shoot myself first.” Nevertheless, knowing it is not dangerous takes away some of the stress, which has been linked to making BPPV worse – as it does with most conditions.
‘Paroxysmal’ is medical jargon that basically means it comes and goes. It doesn’t come and go like a train on a schedule, but more like the occasional and unexpected blimp roaming the skies, rare enough that you shout, “hey look.” While there are possible clues to consider, most medical professionals would respond to a question about ‘when’ or ‘how often’ with what would amount to a virtual shrug, translated as ‘who knows?’ There are no known routines. It may happen multiple times in a month or year or not for many years.
‘Positional’ means the position of your body (specifically neck and head) which influences the condition.
‘Vertigo’ is sometimes decoded as dizziness, but has a unique sensation of ‘spinning.’ Whereas light-headedness or dizzy feelings most often tend to pass after sitting or lying down, the spinning related to vertigo is more persistent. People can report that the ‘room is spinning’ even with their eyes closed and while remaining totally motionless in bed. With BPPV any little movement can increase the vertigo and nausea or produce vomiting. All in all – one big YUCK.
What is It?
My dad was a man of his age, picking up all the colloquial expressions of the day. When he didn’t like something I had done or some plans I had ‘cooked up,’ he would lovingly, but incredulously, ask “WHAT, do you have rocks in your head?” Well surprise, surprise. Yes, I do. But then all of us do. They aren’t even a problem as long as they keep in their place. BPPV happens when they don’t – when instead the rocks start to wander.
All of this movement happens in our inner ears. Affecting nerves which relate to balance, these tiny rocks (small calcium carbonate crystals or debris) may float from one area (a sac-like structure called the utricle) and move to another canal (one of the semi-circular canals). It is not always the same one. [To see these structures, click on the picture to enlarge or zoom in.]
The fluid in these canals is usually quite tranquil and still, but the new debris (most often called otoconia or sometimes canaliths) can disrupt that stillness. Gravity and head movements play a major part because in combination they can cause the ‘rocks’ to move, which in turn (by disturbing the still fluid) stimulate a signal to the brain. That signal to the brain telegraphs that the head is moving although it may not be, and thus creates the vertigo.
While healthy in so many ways, I have long suffered from severe motion sickness (a subject for another blog). But anyone like me who has dealt with this has learned the term ‘vestibular system’ (part of the inner ear and balance organism). BPPV (like motion sickness) is often categorized under an umbrella term of Vestibular System Conditions. While the connection is frequently made in passing, the link or similarity of the two conditions does not have a clear explanation (at least not in my understanding of the literature). Yet, like motion sickness, BPPV demonstrates severe nausea and balance problems related to the vestibular system.
Places like Johns Hopkins Medical and Mayo Clinic treat BPPV regularly. According to them, and much of the related literature, the condition is most common in those over 60 years old, although it can even occur in children.
Diagnosis and Professional Treatment
Nice to know, it is not uncommon for these debris rocks to reabsorb back into place spontaneously, helped along by gravity. It might occur before you actually know what happened – or before you ever get to a family doctor, otorhinolaryngoloist (ENT-Ear-Nose-Throat), physical therapist, chiropractor, or any Vestibular System Expert.
In the doctor’s office, BPPV will be one of their first considerations. There will be an effort to rule out Meniere ’s Disease, which presents in similar ways but with a hearing element, such as inner-ear pressure, tinnitus (like ringing) or hearing fluctuations. To help your practitioner’s effort in confirming your diagnosis (using the common Dix-Hallpike test) she will attempt to discover two important things:
- If you have nystagmus (a type of distinctive involuntary twitching or ‘beating’ in the eye
upon certain movements). This is an important piece of information because it confirms
THAT you have BPPV and conveys WHICH of your semi-circular canals is hosting the
debris. And; - which is your “affected” ear. This allows the practitioner to understand on which side
they will start the treatment maneuver.
BPPV is a mechanical based disorder, and best treated that way. Pharmaceuticals (such as diazepam or medizine used in severe motion sickness) are rarely recommended. Occasionally antiemetic drugs (to stop vomiting) can be used if that is becoming a concern. But normally drugs are not initially considered. I presume that this is predominately because such drugs can cause systemic side-effects to deal with that last much longer than the BPPV symptoms themselves – especially if you respond quickly to the typical management.
Treatment
The good news in all of this is that there is a simple – and HOPEFULLY INEXPENSIVE – treatment for BPPV. First, a few simple, low tech /no tech neurological scans will be performed during the office visit (to rule out the rare possibility of a central lesion). After that the most common treatment is a mechanical movement. It only takes a few minutes AND if your doctor is a team player she may teach you to do it at home for a few days of precautionary measures. [The most common choice is called the Epley maneuver or Canalith Repositioning Maneuver. There are also alternatives such as the Semont or Lempert 360-roll.]
A chiropractor may perform this maneuver as well as a mechanical cervical adjustment when appropriate. Chiropractic literature points out that the areas of the third and fourth cervical vertebrae (C3 and C4) are often involved. Not as common as C1, C2 or C5 adjustments, corrections in this mid area may be a helpful double application for BPPV.
If you do manage to get to the doctor’s office for help, make sure you get the FULL diagnosis. While I would like to add my own descriptive initials to rename this malady, such as BPPV / CBS – Common But Scary, there may be additional and real initials behind your BPPV diagnosis. Take note of them. They indicate the canal that was involved (e.g. posterior, lateral, etc). Furthermore, you should make sure you find out the “affected” ear. While it can change, often it does not. The canal can change even during treatment, but the affected ear changes less frequently.
Self-treament at home using a Canalith Repositioning Maneuver has a good history of success according to Phoenix AZ Neurologist, Terry Fife. These maneuvers and home exercises (like the Brandt-Daroff ones) seem to pose little risk and appear to be a supportive adjunct. [There are many instructive videos on line, here is a quick and clear one done by Dr. Michael Telixido showing the Brandt-Daroff exercise.]
Causes
I mentioned HOW this condition happens, but WHY does BPPV happen? Medical physicians will often throw up their hands and fill in the bubble under diagnosis as ‘idiopathic’ – a short cut for saying ‘I have no idea.’ Technically it means that the reason a condition occurred is unknown. According to Dr. Timothy Hain writing on BPPV, perhaps as many as HALF of all cases are deemed idiopathic.
Physicians (by necessity) are generally more interested in diagnosis and treatment than figuring out the exact origin. You may feel the same, especially if you think you won’t suffer from it often. However, I have been interested in understanding the causes as a way to prepare for prevention – or as they help explain possible approaches to limit or lessen the condition.
Literature has various clues to uncover the causes, and how the blockage or drainage of the canals may develop. After a patient has recently either paid a trip to the hair dresser (leaning head back for a long period) or had extensive and long dental work, any Physical Therapist or Chiropractor can affirm there is obvious mechanical reaction involved. Many (although not all) of the BPPV prompts are mechanical as well. There is actually such a long and varied list of ‘causes’ that one may wonder if anyone really has a solid answer. Some of the listed influences often cited include:
- Sustained head positions
- Infections
- Significant dental work
- Whiplash or head injuries
- Virus
- Neck or sinus surgery
- Cervical muscular imbalances
- Hyperlipidemia (possible). See related issues at AgingwithPizzazz.com – Alzheimer’s & Diabetes Collude
- Migraine triggers
- Loss of homeostasis brought on by electrolyte imbalances
- Meniere’s Disease (surprisingly often listed as a cause)
- ‘Aging’ of Inner Ear *
* I wonder how that ‘affected ear’ got older than the other one? 
BPPV is also often said to be aggravated or exacerbated by a few additional things (some in our control):
- Lack of sleep
- Increased Stress
- Dehydration (including from ‘drying’ drugs or even antibiotics and antihistamines)
- Diarrhea (more than likely referring back to dehydration)
- Change in barometric pressure (especially a few days before rain or snow)
- Sleeping positions.
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WHAT CAN YOU DO?
According to one source, on average most of us will experience an episode of such vertigo in our lives. [i] Understandably some people may figure ‘I’ll just deal with it and get help when it happens.’ If you had it badly (like my patient, Marvin) or even very mildly as I did, you may wish to take steps to avoid it.
Here are a few possible preventative or pro-active behaviors to consider.
Sleeping positions can greatly affect us. [ii] While not enough sleep is an issue, so is spending the night lying on one side without much movement and waking up with a stiff neck. Not surprisingly, there is a correlation at a statistically significant level shown between the “affected ear” and the head side lying down during sleep. [The favorite side of sleeping tends to be the affected ear.] Moving positions during your sleep can aid in reducing this influence.
Dehydration. Many of us drink less than we think. If we have allergies and take over-the-counter drugs like Benadryl or other antihistamines, we can feel the ‘drying’ if we stop to notice it. Antibiotics and post-surgical drugs have a strong effect – as does just not consuming enough liquid. Since hydration has so many other advantages, it is really a no-brainer to adopt. Not everyone will like this suggestion for obvious reasons, but drinking before bedtime will not only deter dehydration, but may help your sleeping position. Sound unrelated? The need to get up in the night to use the ‘loo’ will force more change to your sleeping posture. Advantageous, as long as it doesn’t frequently disturb your efforts to return to sleep.
Homeostasis in the body refers to a balance of our general health. Dehydration and electrolytes are part of this, as are the minerals and vitamins from food or supplements. Literature periodically points out extremely low salt diets as associated with episodes of BPPV. So once again salt is a ‘fine line’ commodity – not too much, but not too little is the sweet spot. [You could think of it as the ‘sweet and salty’ recipe.]
Get all the info you can. As I mentioned before, if you visit the doctor’s office get your full diagnosis (including precise canal involved) and the affected ear. This can supplement information from personal research or for self-treatment at home later.
Final Thought
Like all of us, it’s true I have ‘rocks in my head.’ But I still have my goal of keeping them in place. It had been over 7 years since I had an episode of BPPV before this one, and I can’t say for sure whether my efforts will eliminate or reduce the problem. Still while vertigo may feel like you are getting caught in an avalanche of rocks spinning down the hill, with BPPV gravity can work for you. You don’t have to overly stress about it. It’s going to end. It probably won’t last too very long. And you aren’t alone. So, if BPPV is your diagnosis, there is a bit you can do to prevent it but perhaps the best news is that it isn’t the worst of conditions.
References:
Another good source of information is House Clinic. Visit: https://www.houseclinic.com/balance (accessed September 2015)
Antunes,Marcelo B, MD. CNS Causes of Vertigo. MedScape: http://emedicine.medscape.com/article/884048-overview. Accessed 9/20/2015. [References Central Nervous System causes of Vertigo versus BPPV.]
Asprella-Libonati, G. Pseudo-Spontaneous Nystagmus: a new sign to diagnose the affected side in Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo. Actar Otochinolaryngol Ital.2008 Apr:28(2):73-78. Full article available on various sites. Can download at: http://www.pubfacts.com/fulltext/11960872/A-new-differential-diagnosis-for-spontaneous-nystagmus-lateral-canal-cupulolithiasis
Buttner U., Helmchen C., Brandt T. Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: A review. Acta otolaryngal 1999 119:1-5. [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10219377 ]
Cohen, HS. New epidemiological findings on benign paroxysmal positional vertigo. J Neurol Neurosurg Psychiatry. 2007 Jul; 78(7): 663. doi: 10.1136/jnnp.2006.109447 PMCID: PMC2117669
Labugen, Ronald H, M.D. Initial Evaluation of Vertigo. American Family Physician. Jan 15, 2006. Vol 73, Number 2: 244:251 (www.aafp.org/afp) . Article accessed September 2015 http://emed.chris-barton.com/PDF/Initial%20Eval%20of%20Vertigo.pdf
Lanska DJ. Remler B. Benign Paroxysmal positioning vertigo: classic descriptions, origins of provocative positioning technique and conceptual developments. Neurology 1997, 48:1167-1177. http://www.neurology.org/content/48/5/1167.short
Li JC; Li CJ. Epley J.; Weinberg L: Cost-effective management of benign positional vertigo using canalith repositioning. Otolaryngol Head Neck Surg 2000. 122:334-339.. Abstract at http://www.sciencedirect.com/science/article/pii/S019459980070043X
Solomon, David, MD.Phd. Benign Paroxysmal Positional Vertigo. Current Treatment Options in Neurology 2000, 2:417-427 http://www.med.upenn.edu/solomon/images/BPPV.pdf
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EndNotes
[i] Fife, Terry D., MD. Benign Paroxysmal Positional Vertigo. Seminars in Neurology 2009-29 (5):500-508
[ii] Shim DB, Kim, JH, Park KC, Song, MH, Park HJ. Correlation between the head-lying side during sleep and the affected side by benign paroxysmal positional vertigo involving the posterior or horizontal semicircular canal. Laryngoscope. 2012 Apr:122(4):873-6.
