What is BPPV?
BPPV (Benign Paroxysmal Positional Vertigo) is the most common cause of vertigo. It occurs when tiny calcium carbonate crystals — called otoconia or "ear rocks" — become dislodged from their normal position in the utricle and migrate into one of the semicircular canals of the inner ear.
When these crystals move through the canal during head movements, they send false signals to the brain about your head's position and movement. The result is a brief but intense spinning sensation (vertigo) that's typically triggered by specific head positions — rolling over in bed, looking up, or bending down.
Common symptoms
- Brief spinning vertigo lasting 15–60 seconds, triggered by head position changes
- Nausea during or after vertigo episodes
- Unsteadiness or lightheadedness between episodes
- Nystagmus — involuntary eye movements visible during positional testing
How we diagnose BPPV
At Burlington Vestibular Therapy, your physiotherapist will perform specific positional tests — most commonly the Dix-Hallpike test — to confirm which semicircular canal is affected and which side. This involves moving your head and body into specific positions while your therapist observes your eye movements.
The pattern and direction of your nystagmus (involuntary eye movements) tells us exactly which canal is involved, which determines the correct treatment technique.
How BPPV is treated
BPPV is treated with canalith repositioning manoeuvres — specific sequences of head and body movements that guide the displaced crystals back to their correct location in the inner ear.
Epley manoeuvre
The Epley manoeuvre is the most commonly used treatment for posterior canal BPPV (the most common type). It involves a series of four head position changes, each held for about 30 seconds, that move the crystals through the semicircular canal and back into the utricle.
Semont manoeuvre
The Semont manoeuvre (or liberatory manoeuvre) is an alternative technique that uses rapid side-to-side movements to dislodge the crystals. It may be used when the Epley is not effective or not suitable.
Other techniques
For less common types of BPPV (horizontal canal or anterior canal), your therapist may use the BBQ roll, Gufoni manoeuvre, or Yacovino manoeuvre — specialized techniques designed for those specific canal variants.
How effective is treatment?
BPPV treatment is one of the most effective interventions in all of physiotherapy:
- Most patients experience significant relief after a single treatment session
- 85–90% of cases are resolved within 1–3 visits
- The entire treatment takes only a few minutes per session
After treatment, your therapist will provide guidance on sleeping positions and head movements to help prevent recurrence in the days following your appointment.
What causes BPPV?
In many cases, the exact trigger is unknown. However, several factors are associated with a higher likelihood of developing BPPV:
- Age — BPPV is most common in adults over 50, likely due to natural degeneration of the otoconia
- Head trauma — even minor head injuries can dislodge the crystals
- Prolonged bed rest — extended periods lying down (e.g., after surgery or illness) increase the risk
- Inner ear infections — conditions like vestibular neuritis can lead to secondary BPPV
- Vitamin D deficiency — some research suggests a link between low vitamin D levels and recurrent BPPV
Women are also affected roughly twice as often as men, though the reasons for this are not fully understood.
What to expect during your visit
Your first visit at Burlington Vestibular Therapy takes approximately 60 minutes. Here's what happens:
- History review — we discuss your symptoms, when they started, what triggers them, and any relevant medical history
- Positional testing — the Dix-Hallpike test and, if needed, the supine roll test to identify which canal is affected
- Treatment — if BPPV is confirmed, we perform the appropriate repositioning manoeuvre during the same visit
- Post-treatment guidance — instructions on sleeping positions, activity modifications, and what to expect in the days following treatment
Most patients feel significantly better immediately after treatment, though mild unsteadiness can linger for a day or two as the vestibular system recalibrates.
Can BPPV come back?
Yes — BPPV has a recurrence rate of approximately 15–20% within the first year. If it does return, the same repositioning techniques are effective again. Your therapist can also teach you a home version of the Epley manoeuvre (the modified Epley) to manage any recurrence on your own.
Certain lifestyle adjustments may help reduce the chance of recurrence:
- Sleeping on an elevated pillow for 1–2 nights after treatment
- Avoiding extreme head-tilt positions temporarily
- Maintaining adequate vitamin D and calcium intake
- Staying active — regular physical activity supports vestibular health
BPPV vs other causes of vertigo
Not all vertigo is BPPV. Other conditions that can cause spinning sensations include vestibular neuritis, Ménière's disease, and post-concussion vestibular dysfunction. The key differences:
- BPPV — brief episodes (under 60 seconds), triggered by specific head movements, no hearing changes
- Vestibular neuritis — prolonged vertigo lasting hours to days, often after a viral illness
- Ménière's disease — vertigo episodes lasting 20 minutes to several hours, with hearing fluctuation and ear fullness
- Post-concussion — persistent dizziness and visual motion sensitivity following a head injury
A thorough vestibular assessment can differentiate between these conditions and determine the most effective treatment approach.
When to seek vestibular therapy for BPPV
If you're experiencing brief episodes of spinning vertigo triggered by head movements — especially rolling over in bed, looking up, or bending down — it's very likely BPPV. No referral is needed in Ontario. Book your vestibular assessment today and we can typically diagnose and treat it in your first visit.
Don't wait it out. While BPPV sometimes resolves on its own, it can persist for weeks or months without treatment, and the repositioning manoeuvres used to treat it are quick, non-invasive, and highly effective.
Learn more about vestibular therapy, the Epley manoeuvre explained, and the full range of conditions we treat.