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Vertigo from inner ear crystals

Also called: BPPV; benign paroxysmal positional vertigo

See someone before self-treating

Intense spinning lasting under a minute, triggered by rolling over in bed or looking up. Crystals have moved into a balance canal where they do not belong - and a repositioning manoeuvre cures it in minutes.

How common: 2.4% lifetime prevalence; the commonest cause of vertigo

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What it is

Benign paroxysmal positional vertigo is caused by tiny calcium crystals - otoconia - that normally sit in one part of the inner ear becoming displaced into one of the semicircular canals. When the head moves, they move, and the canal reports rotation that is not happening.

It is the single most common cause of vertigo, and it is also one of the very few conditions in medicine that can be cured in one appointment. A repositioning manoeuvre moves the crystals back where they belong, and it works in the large majority of people, often immediately. It is not a muscular problem and no exercise programme treats it.

What it feels like

  • Intense spinning triggered by a specific head movement - rolling over in bed, lying down, looking up
  • Lasting seconds to under a minute, then stopping
  • Nausea and sometimes vomiting with the attacks
  • A residual unsteady, off-balance feeling between attacks
  • Reproducible by the same movement every time, which is characteristic

What causes it

Most people have more than one of these at once, and they feed each other. Read the list looking for the two or three that sound like your week rather than for the one true answer — the ones that describe you are the ones worth acting on.

Displaced otoconia in a semicircular canal
Calcium crystals that normally sit in the utricle move into a semicircular canal. When the head moves they shift under gravity and stimulate the canal, which reports a rotation that is not occurring.
Age
The commonest single factor. The membrane holding the crystals degenerates with age, and prevalence rises steeply after fifty.
Head injury
Even a minor knock can dislodge crystals. It is one of the most common identifiable precipitants in younger people.
Prolonged bed rest or lying still
A period in bed after illness or surgery is a recognised trigger, probably by allowing crystals to settle in the wrong place.
Vestibular neuritis or other inner ear disease
A previous inner ear problem raises the risk of subsequently developing positional vertigo.
Osteoporosis and low vitamin D
Associated with both incidence and recurrence, plausibly through effects on the calcium crystals themselves. Correcting vitamin D reduces recurrence in trials.
Migraine
Associated with a higher incidence, and vestibular migraine is one of the main conditions it needs distinguishing from.
Dental and ENT procedures
Prolonged head positioning during procedures has been reported as a trigger.
Being treated as something else
Frequently attributed to blood pressure, to the neck or to general unsteadiness. Given that a single manoeuvre cures it, the misdiagnosis is unusually costly.

Who tends to get it

  • Adults over fifty, in whom it is most common
  • Women, in whom it is around twice as common
  • Anyone who has had a head injury, however minor
  • People who have had a period of bed rest
  • Anyone with osteoporosis, low vitamin D or migraine

What makes it worse, and what settles it

Makes it worse

  • Avoiding the triggering movement, which prevents diagnosis and does not resolve it
  • Long-term vestibular sedative medication, which suppresses symptoms and prevents adaptation
  • Being treated as a neck problem or as general dizziness
  • Delaying assessment, since the treatment is quick and effective
  • Driving or working at height while symptomatic

Settles it

  • Getting the diagnosis, which is made by a positional test in a few minutes
  • A repositioning manoeuvre - the Epley or a variant - which cures the majority in one or two treatments
  • Learning the manoeuvre for home use where it recurs, which many people can do
  • Getting vitamin D checked and corrected, which reduces recurrence
  • Balance work afterwards if unsteadiness persists

What actually helps

The short version: Displaced otoconia in a semicircular canal. It is a mechanical inner-ear problem, not a muscular one

Strength work: Not effective

Stretching: Not effective

Massage: Not effective

Also worth doing: Epley or Semont repositioning maneuvers resolve 80-90% in one or two treatments

What the evidence says: SECOND NEGATIVE ENTRY: neck stretching is commonly and wrongly offered for dizziness. If a user reports positional vertigo lasting under a minute, the right answer is a repositioning maneuver from a clinician, not a routine.

The names above are the Targets qFIT tracks — the Muscle Guide explains what each one does, and Quick Add switches on the Exercises you already have.

No ready-made routine for this one yet

249 of the 267 problems here have a routine already built, and this is not one of them — usually because the work that helps is covered by a general routine rather than needing its own. What actually helps above names the muscles and the work involved, which is enough to put it together yourself.

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Get it checked if…

Vertigo with hearing loss, double vision, slurred speech or weakness is not BPPV - emergency

And whatever the body part: chest pain or unusual breathlessness on exertion; a fever alongside the pain; unexplained weight loss; pain that is constant and unrelated to how you move; new numbness, weakness or loss of bladder or bowel control; or one calf that is swollen, warm and painful. Any of those, stop and get assessed.

How it usually goes

A repositioning manoeuvre resolves symptoms in the large majority of people, often after a single treatment, which makes this one of the most satisfying diagnoses in medicine. Recurrence happens in a substantial minority over the following years and responds to the same treatment. Vertigo that lasts hours rather than seconds, that comes with hearing loss, or that is accompanied by double vision, weakness, slurred speech or severe headache is not this and needs urgent assessment.

Prevalence basis: Vestibular epidemiology

This is general information, not a diagnosis, and it cannot examine you. If it matches you, use it to ask better questions of a clinician rather than to replace one.

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