BPPV Vertigo: The 5-Minute Fix Most GPs Don't Know
Quick answer: Benign paroxysmal positional vertigo (BPPV) causes brief episodes of spinning triggered by head movement - rolling over in bed, looking up, or tilting the head back. The fix is mechanical: a repositioning manoeuvre (most commonly Epley) performed by a trained physiotherapist. One session resolves symptoms in roughly 80% of cases, and most of the rest resolve after a second session a week later. Medication does not fix BPPV - only repositioning does.
What BPPV feels like
You roll over in bed, and the room spins for 10-30 seconds. You sit up, and the world tilts. You look up to a shelf and your balance is gone for a moment. Episodes are brief, triggered by position changes, and do not come with hearing loss or ringing (that would point elsewhere - see your GP to rule out Meniere's or vestibular neuritis).
Between episodes, many people feel a residual unsteadiness or "brain fog" - this is normal and settles with the underlying cause.
Why it happens
Your inner ear has three fluid-filled canals that sense head rotation. Tiny calcium carbonate crystals (otoconia) normally sit in a different chamber. When one breaks loose and drifts into a semicircular canal - usually the posterior canal - moving your head moves the crystal, which drags the fluid, which fires the hair cells. Your brain interprets that as rotation. The room "spins."
Ageing is the most common trigger; head injury, dental procedures, or simply sleeping with the head turned to one side can also displace crystals. BPPV is the most common cause of vertigo over age 50.
The diagnosis
A physiotherapist trained in vestibular rehabilitation performs the Dix-Hallpike test: you sit on the couch, they rotate your head 45° to one side, then lower you quickly so your head hangs over the edge. If BPPV is in the posterior canal on that side, within 5-10 seconds your eyes will beat in a characteristic rotational nystagmus, and you will feel the vertigo. The direction of nystagmus tells us which canal and which side.
If Dix-Hallpike is negative both sides, the roll test (for lateral canal BPPV) is next. Less than 5% of BPPV is in the anterior canal.
The Epley manoeuvre
For posterior canal BPPV, the Epley repositioning manoeuvre walks the crystal back out of the canal in four positions, each held for 30-60 seconds until any vertigo or nystagmus settles:
- Sit on the couch, turn head 45° to the affected side.
- Lie back quickly so head hangs off the edge (still turned).
- Turn head 90° to the unaffected side.
- Roll the body onto that side so you're looking at the floor.
- Sit up slowly.
Most people feel a brief spin in position 2 (the crystal moving), then much less in subsequent positions. By the time you sit up, symptoms are usually markedly better.
After the manoeuvre
Older protocols told patients to sleep upright for 48 hours. Current evidence does not support this - there's no added benefit over normal activity. You can go about your day. Avoid sleeping on the treated side for 24 hours just as a precaution.
Residual unsteadiness for a few days is normal - your brain is recalibrating. A short programme of gaze-stabilisation and balance exercises speeds this up.
When BPPV isn't the answer
Physiotherapy screens for red flags: new hearing loss, ringing, persistent (not positional) vertigo, weakness, double vision, or difficulty speaking - any of these mean we refer you for medical workup. Not every dizzy spell is BPPV.
In Ipoh
Vestibular physiotherapy is a niche skill - not every clinic does it. Expect RM120-180 for the assessment and first manoeuvre, and typically one follow-up if symptoms persist. WhatsApp us and we'll match you with a physio trained in Dix-Hallpike and Epley.
Recovery timeline: 80% symptom-free after one session. The remaining 20% usually need a second session within a week. Recurrence is 15-20% per year - know the manoeuvre or return if it comes back.