You Spin Me Round (Like A Record)
On a recent Saturday morning I woke up and turned over to grab my phone to see what time it was. All of a sudden WHOOMP, the whole world flipped upside down. “Uggggghhhh”, I moaned as I lay there motionless, trying to explain to my husband what I was wailing about. Vertigo.
Unfortunately, this wasn’t my first experience with Benign Paroxysmal Positional Vertigo (BPPV). I had my first bout with BPPV over 20 years ago, under the same circumstances (went to bed fine, woke up in the morning and turned over to discover the whole world flipped upside down.) At that time I had no idea what was going on. At least this time I did.
BPPV is the most common disorder of the inner ear’s vestibular system. 2.4% of people will experience it in their lifetime. Let’s first talk about the name of the disorder.
Benign indicates that it is not life threatening and generally doesn’t progress.
Paroxysmal indicates sudden onset of symptoms.
Positional refers to the fact that the symptoms usually occur with changes in head position.
Vertigo is a spinning sensation.
How does it happen?
Our vestibular organs in our inner ear consist of the utricle, saccule and 3 semicircular canals. The semicircular canals detect rotational movement of the head. When the head rotates the fluid exerts pressure against the cupula, the sensory receptor at the base of the canal. The receptor then sends impulses to the brain about the head’s movement.
BPPV occurs when the otoconia (tiny crystals of calcium carbonate that are a normal part of the inner ear’s anatomy) detach from the otolithic membrane in the utricle and collect in one of the semicircular canals. When the head is still, the otoconia settle. When the head moves, the otoconia shift. This stimulates the cupula to send false signals to the brain, producing vertigo and triggering nystagmus (involuntary eye movements). See more here.
What causes it?
The most common cause of BPPV in people under 50 years old is trauma. About five years ago, I wiped out skiing and hit my head hard (I was wearing a helmet, thank goodness). I sustained a concussion and took a nice trip down the mountain in the ski patrol sled. Following that incident, I developed BPPV and had treatment that resolved the issue. Any impact to the head can cause BPPV, and anyone who has suffered a concussion should be evaluated for it.
In folks over 50, the cause is generally unknown. It might possibly be caused by age related degeneration of the otolithic membrane.
Sometimes the cause of BPPV is a virus affecting the ear and causing vestibular neuritis. Less commonly, it can be related to Meniere’s disease.
Ugh! What does it feel like?
BPPV most commonly occurs when going from sitting to lying down, when turning over in bed, or when looking up. The sensation of vertigo (spinning) can last from a few seconds to a minute, and can make you feel nauseous. Typically, only one side is affected, and you will feel the vertigo when turning to one side or looking up in a certain direction (hence the “positional” in the name).
How is BPPV diagnosed?
Clinically, BPPV is diagnosed by looking for nystagmus (involuntary eye movements) and vertigo when the head is placed in certain positions. This is called the Dix-Hallpike maneuver. Sometimes lab work may be ordered to rule out other causes of BPPV.
How is it treated?
When BPPV strikes, you will want to get rid of it as soon as possible (it’s that miserable). Medications are not effective in treating BPPV, as they mask the symptoms and can sometimes cause more harm (I was prescribed Meclizine, a motion sickness medication, which I didn’t take).
The most common treatment is a Cannalith Repositioning Procedure (CRP), usually called the Epley Maneuver. This treatment can be performed by a physical therapist or an ENT who specializes in vestibular issues. You will be taken through a series of four movements that move the otoconia back into the utricle, where they no longer stimulate the cuppula.
You should always have this condition evaluated and treated by a physical therapist or ENT, but I will share the steps of the Epley Manuever here:
FOR LEFT EAR PERFORM AS SHOWN ABOVE:
(FOR RIGHT EAR REVERSE SEQUENCE WITH TURNING HEAD TO RIGHT TO BEGIN)
- SIT WITH LEGS OUT IN FRONT OF YOU, 1-2 PILLOWS BEHIND BACK
- TURN HEAD 45 DEGREES TO LEFT (OR SIDE OF AFFECTED EAR)
- LIE BACK QUICKLY KEEPING 45 DEGREES ROTATION WITH EXTENDING OVER PILLOWS: HOLD 30 SECONDS
- ROTATE HEAD TO RIGHT SIDE AT 45 DEGREE ANGLE: HOLD 30 SECONDS
- ROLL TO RIGHT SIDE KEEPING CHIN TO SHOULDER, REMEMBER DO NOT PICK UP HEAD, HOLD 30 SECONDS
- THEN SIT ON EDGE OF BED WITH HEAD DOWN FOR 30 SECONDS
REPEAT SEQUENCE IF STILL DIZZY UP TO 3 TIMES IN A ROW.
Wait 24 hours before you perform the full sequence again.
It can be uncomfortable to go through this maneuver because it first puts you in the position that brings on the vertigo, and then you often feel the vertigo again during the repositioning. The procedure is often effective the first time, although it may need to be repeated for complete relief from symptoms. Some patients are given vestibular exercises to do at home as a follow up.
Happily, I can report that my symptoms were almost 100% resolved after doing this maneuver 2 nights in a row. The unfortunate news is that BPPV recurs in 1/3 of patients after 1 year, and in 50% of patients within 5 years. At least I know what to do if it strikes again!
Have you ever experienced vertigo? What do you do for treatment?