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BPPV: The Most Common Cause of Vertigo — and One of the Most Treatable
By DEB’s Audiology Team – March 2026 – 15 min read
Article Summary
Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder in India, affecting an estimated 107 people per 100,000 each year. It is also one of the most frequently mismanaged, with patients often prescribed medication that treats the symptom rather than the cause.
This article covers:
- What BPPV is and the ‘crystals in the ear’ explanation in plain language
- What it feels like and how to distinguish it from other types of dizziness
- What causes crystals to become dislodged — and why it is more common in women and older adults
- How it is diagnosed using the Dix-Hallpike manoeuvre
- How the Epley manoeuvre repositions the crystals — step by step, as performed at the clinic
- Recurrence rates and what to do if BPPV returns
The key takeaway: BPPV has a 90% success rate with the Epley manoeuvre when correctly performed by a trained audiologist. Most patients leave their first appointment with significant or complete relief.
If you have ever woken up, turned in bed, and felt the room spin violently for several seconds, you may have experienced BPPV. It is frightening the first time it happens. It is also, in most cases, straightforward to fix.
BPPV — Benign Paroxysmal Positional Vertigo — is the most common vestibular disorder in India. It accounts for more than half of all cases of peripheral vertigo seen in specialist clinics. Yet it is widely undertreated, because it is commonly managed with medication rather than the simple repositioning procedure that actually resolves it.
What Is BPPV?
BPPV is a disorder of the inner ear in which tiny calcium carbonate crystals — called otoconia, or informally ‘ear crystals’ — become dislodged from their normal position and migrate into one of the inner ear’s semicircular canals.
These canals are fluid-filled tubes that detect head rotation and send signals to the brain about movement. When loose crystals enter a canal, they move with the fluid when the head changes position — sending incorrect balance signals to the brain. The brain interprets this as movement that is not happening. The result is the sudden spinning sensation that defines BPPV.
The word ‘benign’ in BPPV is important. It means the condition is not dangerous and does not indicate a serious underlying problem. ‘Paroxysmal’ means it occurs in sudden, brief episodes. ‘Positional’ means it is triggered by changes in head position.
What Does BPPV Feel Like?
BPPV produces a sudden, intense spinning sensation — either you feel like you are spinning, or the room around you is. Episodes are brief, typically lasting between ten seconds and a minute, and they stop when the head becomes still.
Classic triggers include rolling over in bed, sitting up from lying down, tilting the head back to look up (a common problem when reaching for something on a high shelf), or bending forward. The vertigo is often accompanied by nausea. In some cases it causes vomiting.
Between episodes, many people with BPPV feel fine. Others experience a persistent low-level unsteadiness or a ‘floaty’ feeling throughout the day. BPPV does not usually cause ringing in the ears or hearing loss — if those symptoms are present alongside positional vertigo, another condition may be involved.
What Causes BPPV?
In the majority of cases — around 70% — BPPV is idiopathic, meaning no specific cause is identified. The crystals simply dislodge. In the remaining cases, an identifiable cause is present.
Known risk factors and associated causes include:
- Age — BPPV is most common in adults in their 50s to 70s
- Female sex — women are 2 to 3 times more likely to develop BPPV than men
- Head injury or trauma — even a mild knock can dislodge crystals
- Prolonged bed rest or immobility, including after surgery
- Vitamin D deficiency — linked to increased BPPV incidence in Indian populations
- Other inner ear conditions, including vestibular neuritis and Ménière’s disease
- Osteoporosis — associated with crystal instability
Understanding the cause — particularly if it is recurrent BPPV — can help reduce the risk of future episodes.
How Is BPPV Diagnosed?
BPPV is diagnosed using the Dix-Hallpike manoeuvre, a straightforward clinical test that is the gold standard for BPPV diagnosis. You sit on the examination table, and the audiologist guides you from a sitting position to lying with your head turned to one side. The audiologist then observes your eyes for a specific pattern of involuntary movement called nystagmus, which confirms that displaced crystals are present in the canal.
The Dix-Hallpike is quick, safe, and highly accurate. It also tells the audiologist which ear is affected and which canal the crystals have entered — information that is essential for performing the correct treatment manoeuvre.
BPPV can sometimes be confused with other vestibular conditions or, more seriously, with neurological problems. A trained audiologist performing a thorough vestibular assessment is best placed to confirm the diagnosis and rule out other causes.
How Is BPPV Treated?
The Epley Manoeuvre
The Epley manoeuvre is the first-line treatment for BPPV and the most effective non-drug intervention available. Clinical studies consistently show a success rate of 80 to 90% after one or two sessions. At DEB’s Audiology, the manoeuvre is performed by Dr. Sarmistha Nayak, who has specialist training in vestibular repositioning techniques.
The procedure involves guiding the patient’s head through four specific positions, each held for approximately 30 seconds. These movements use gravity to shift the displaced crystals out of the semicircular canal and into the vestibule — an area where they no longer cause symptoms and are eventually reabsorbed by the body.
The manoeuvre takes 10 to 15 minutes. It is not painful. Some patients experience a brief intensification of vertigo during the procedure as the crystals move — this is a normal and expected part of the process.
Vestibular Rehabilitation Therapy
For patients whose BPPV does not fully resolve with the Epley, or who have a more complex vestibular picture, vestibular rehabilitation therapy (VRT) may be recommended. VRT is a structured programme of exercises designed to help the brain compensate for vestibular dysfunction and reduce dizziness in daily activities.
What to Expect on the Day
When you come to DEB’s Audiology with suspected BPPV, the assessment begins with a detailed case history. The audiologist will ask which head movements trigger your vertigo, how long episodes last, and whether you have had similar symptoms before.
The Dix-Hallpike test is then performed to confirm the diagnosis. If BPPV is confirmed, the Epley manoeuvre is typically carried out in the same appointment. A repeat Dix-Hallpike test afterwards checks whether the crystals have repositioned successfully.
You will be given post-procedure guidance: sleep with your head slightly elevated for the first night and avoid lying completely flat. Most patients experience significant improvement immediately or within 24 hours.
If possible, arrange to be driven home after your appointment. Some patients feel briefly unsteady following the procedure.
Can BPPV Come Back?
Yes. BPPV has a recurrence rate of approximately 50% within five years. This is not a failure of treatment — it simply reflects the nature of the condition. Crystals can dislodge again, particularly in people with the associated risk factors listed above.
Recurrent BPPV is treated in exactly the same way as the initial episode. Patients who have been through the assessment and treatment once often recognise future episodes quickly and seek treatment promptly — which makes the second and subsequent episodes less disruptive.
If BPPV is recurring frequently, investigating underlying contributing factors — particularly vitamin D levels and bone density — may reduce the frequency of future episodes.
What to Do Next
If positional vertigo is disrupting your daily life, a vestibular assessment at DEB’s Audiology will confirm whether BPPV is the cause — and if it is, treatment can begin the same day.
