Your spinning head: Vertigo and BPPV

“It feels like everything is spinning.”

BPPV simple summaryIf things are spinning, you might be suffering from vertigo — and more specifically, Benign Paroxysmal Positional Vertigo (BPPV). BPPV can present as dizziness, unsteadiness, the sensation of nausea or the need to vomit, and of course spinning. Usually, this condition is considered “idiopathic” — which means in most cases no single event or factor is identified as the ‘reason’ the spinning started. Ie. It’s generally not something that you have done to cause this. BPPV is not something the majority of people get to experience, but it is among the more common diagnoses in dizziness clinics (20-30%). One group estimates that 2.4% of people will experience BPPV in their lifetime, and 0.6% of people experience a new episode each year. Doesn’t seem like much? If we extrapolate those rates to Canada, there are approximately 210 000 new cases of BPPV each year.

Can I do something about this?

Yes! Although BPPV tends to get better with time, it tends to get better much faster with treatment. In particular, there are positional treatments (such as Epley’s manoeuvre) that show effective results. In the graph below, you can see the difference in how vertigo symptoms changed for people who received treatment with the Epley manoeuvre compared to those who went untreated. This type of improvement is consistently reported across several different studies, and you can usually receive this form of treatment from a healthcare professional — ie. chiropractors, physiotherapists, medical doctors, etc.

BPPV recovery time

Sekine K et al., 2006.

Why does BPPV happen at all?

There are a couple different theories on why you develop spinning sensations. But first, your anatomy:

BPPV is an inner ear issue — in essence it is a malfunctioning inner ear. Immediately below, you can see the general shape of your inner ear. Important for determining our balance, there are three semicircular canals: the lateral, anterior, and posterior canals. This image is not greatly important for understanding BPPV, but it certainly helps us understand that our inner ear is a complex, sophisticated system.

BPPV anatomy

More important to understanding BPPV, one of these canals (the most commonly involved is the posterior canal) is isolated below. Each canal is filled with fluid, and with head rotation to the left (as depicted), for example, the fluid is pushed to the right. So there is fluid in the canal, which flows in the opposite direction to head movement, and ultimately pushes the cupula as a result (the white-ish structure under the word ampulla). Attached to the cupula are fine hair-like structures, which attach to Cranial Nerve VIII (the vestibulochochlear nerve) — a direct connection to our brain.

So all together then, movement of our head causes the fluid inside the canals to flow in the opposite direction of our body’s movement, pushing on the cupula, which stimulates the hair-like structures below and sends a nerve signal to the brain about our movement. This occurs simultaneously in all three canals, and it is a mix of these signals that allows our brain to interpret what our head is doing (if it is spinning, doing nothing, looking left or right, etc).

Vertigo interpretation

Unfortunately, occasionally things go wrong. Our two theories then.

  1. Calcium crystals, called otoconia, are usually adhered to the utricle (see image above). However, occasionally these crystals become dislodged and enter the semicircular canals. When enough of these crystals collect, they begin to influence the flow of fluid, which impacts the cupula movement, which alters the signal sent through the nerve. This is called “canalithiasis”.
  2. The other commonly discussed possibility is that the calcium crystals adhere themselves to the cupula, changing how it reacts to the fluid forces, which changes the signal to the nerve as well. This is called “cupulolithiasis”.

So with just a small disruption in this movement-sensing system, and you end up feeling like you are spinning, when you are definitely not spinning. The positional treatments discussed earlier aim to restore normal activity in the inner ear — either by dispersion of the crystals, or returning them to the utricle.

In Summary

Sometimes summary paragraphs feel redundant — more of the same from the same source. With that in mind, here is an excerpt from the abstract of an article published in the Canadian Medical Association Journal in 2003 — it provides a nice summary:

“There is compelling evidence that free-floating endolymph particles in the posterior semicircular canal underlie most cases of benign paroxysmal positional vertigo (BPPV). Recent pathological findings suggest that these particles are otoconia, probably displaced from the otolithic membrane in the utricle. They typically settle in the dependent posterior canal and render it sensitive to gravity. Well over 90% of patients can be successfully treated with a simple outpatient manoeuvre that moves the particles back into the utricle.”

Dr. Jim GilliardDr. Jim Gilliard is a chiropractor in Burlington, ON — if you have questions, comments, or wish to book an appointment, contact him at your convenience by leaving a comment below, visiting his website, via email at, by phone at (905) 634-6000, or in person at Endorphins Health and Wellness Centre.

Please do not substitute this article for a consultation with a health professional about your symptoms — always consult with a health professional to ensure accurate diagnosis, safe treatment, and fast recovery. This article is not intended to replace said consultation nor encourage self-diagnosis.

  1. Fyrmpas G, Rachovitsas D, Haidich AB, Constantinidis J, Triaridis S, Vital V, et al. Are postural restrictions after an Epley maneuver unnecessary? First results of a controlled study and review of the literature. Auris Nasus Larynx. 2009;36(6):637–43.
  2. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews. 2014; 12, accessed from
  3. Oliveira AK de S, Suzuki FA, Boari L. Is it important to repeat the positioning maneuver after the treatment for benign paroxysmal positional vertigo? Brazilian J Otorhinolarngology. Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial; 2015;81(2):197–201.
  4. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). Can Med Assoc J. 2003;169(7):681–93.
  5. Seehusen DA, Chaffee III DM. The Epley Maneuver for Treatment of Benign Paroxysmal Positional Vertigo. Am Fam Physician. 2015.
  6. Sekine K, Imai T, Sato G, Ito M, Takeda N. Natural history of benign paroxysmal positional vertigo and efficacy of Epley and Lempert maneuvers. Otolaryngol – Head Neck Surg. 2006;135(4):529–33.
  7. Smouha EE. Time course of recovery after Epley maneuvers for benign paroxysmal positional vertigo. Laryngoscope. 1997;107(2):187–91.
  8. von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78:710–5.

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