Benign paroxysmal positional vertigo (BPPV) is characterized by brief spinning sensations, usually lasting less than 1 minute, which are generally induced by a change in head position with respect to gravity.
BPPV must be distinguished from other, more serious causes of acute or episodic vertigo. A history taking and neurologic examination often allow for differentiation among stroke, vestibular neuritis, and BPPV.
Differential Diagnosis of Acute Vertigo
| Cause | Onset and Course | Nystagmus | Auditory Symptoms | Other Features |
| BPPV* | Recurrent, transient, positional; usually provoked by turning over or getting in and out of bed | Positional, with mixed vertical torsional nystagmus in BPPV involving posterior canal and horizontal nystagmus in BPPV involving horizontal canal | None | Recent inciting event possible (e.g., recumbent position at dentist’s office or hair salon, prolonged bed rest, head trauma); history of similar episodes |
| Stroke | Spontaneous, usually sustained; may be worsened by positional change | Spontaneous, with beating in various or changing directions | Occasional | Neurologic symptoms or signs may include headache and vertical misalignment of eyes; results of head impulse test typically normal† |
| Vestibular neuritis | Spontaneous, sustained; may be worsened by positional change | Spontaneous, predominantly horizontal | None | May be preceded by viral illness; results of head-impulse test abnormal† |
| Vestibular migraine | Recurrent, spontaneous; duration for minutes to hours; may be positional | Rare, but when present usually positional | Occasional | Migrainous headaches, motion sickness, family history |
| Meniere’s disease | Recurrent, spontaneous; typical duration for hours | Spontaneous, horizontal | Fluctuating hearing loss, tinnitus | Ear pain, sensation of fullness in ear |
* BPPV denotes benign paroxysmal positional vertigo.
† In the head-impulse test, the result is considered abnormal when a corrective movement (saccade) is required to maintain straight-ahead fixation after the head has been rotated to the side.
References:
- Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014 Mar 20;370(12):1138-47 [Medline]
- von Brevern M. Benign paroxysmal positional vertigo. Semin Neurol. 2013 Jul;33(3):204-11. [Medline]
Created Jul 23, 2014.
