BPPV is caused by tiny calcium crystals (otoconia) becoming dislodged inside the inner ear’s semicircular canals. Normally these crystals sit in the utricle and play a role in sensing gravity and head position. When they break free and roll into a canal, they trigger false signals to the brain about head movement — producing brief but intense vertigo with specific head positions.

It is “benign” in the medical sense (not life-threatening) and “positional” because symptoms are triggered by specific positions — usually rolling in bed, lying down, looking up, or bending forward.

The classic BPPV pattern: vertigo that lasts seconds to less than a minute, triggered by specific head positions (especially rolling in bed). Between episodes you feel normal.

If your dizziness is constant, lasts hours, comes with hearing loss, severe headache or weakness, it is probably not BPPV and you should see your GP urgently. Vestibular neuritis, Ménière’s, vestibular migraine and stroke can all mimic BPPV in lay terms but have very different causes and treatments.

The definitive in-clinic test is the Dix-Hallpike manoeuvre, which we perform at every BPPV assessment.

Often there is no clear cause. Known risk factors include head injury (even minor), prolonged time lying flat (eg dental work, surgery, illness), inner-ear infection, vestibular migraine, and ageing. Women are affected more than men. BPPV becomes more common after age 60.

Treatment is mechanical, not medication. A vestibular physiotherapist performs canalith repositioning manoeuvres to roll the displaced crystals out of the canal and back into the utricle where they belong.

The two most-used manoeuvres are the Epley (for posterior canal BPPV, the most common form, about 80% of cases) and the Semont liberatory manoeuvre. For horizontal canal BPPV we use the BBQ roll. Each manoeuvre takes 2–3 minutes once we know which canal is affected.

Vertigo medications (eg betahistine, prochlorperazine) can dampen symptoms but do not fix the underlying problem. Repositioning manoeuvres do.

30 minutes. We take a detailed history, perform oculomotor and gaze stability tests, check head-impulse testing for vestibular asymmetry, and perform the Dix-Hallpike to confirm BPPV and identify the affected canal.

If BPPV is confirmed and you are comfortable, we perform the appropriate repositioning manoeuvre the same day. You may feel a brief recurrence of vertigo during the manoeuvre — that is normal and tells us the manoeuvre is working.

After the manoeuvre we usually advise sitting upright for 10–15 minutes and avoiding sudden head movements for the rest of the day. Many patients are symptom-free by the next morning.

BPPV can recur — roughly 15–30% of patients have a recurrence within 12 months. If it returns, treatment is again typically 3 sessions. We teach patients self-administered repositioning (Epley at home) for use if mild recurrence happens between appointments.

If recurrences become frequent (more than 2–3 per year), we look more carefully for underlying contributors like vestibular migraine, head trauma history, or systemic conditions that affect inner-ear function.