Updated: Jan 10
Calling dizziness vertigo is like calling all dogs German Shepherds, and it’s because very few people know what vertigo truly is. Vertigo is a symptom of many different disorders and is used to describe the sensation of spinning even while someone is not physically be moving.
To understand what causes vertigo, we must first learn about an under-appreciated system in the body called the vestibular system. The vestibular system is made up of the inner ear and certain parts of the brain. It is responsible for the sensation of acceleration through space, up vs. down, and that all-too-familiar stomach ache when you ride a rollercoaster. So how does the vestibular system make someone dizzy? Let’s find out! If you want to check out my summarized explanation of BPPV and how it is diagnosed, you can check out our IGTV video here.
1. Do you have BPPV?
It’s important to determine whether or not you have BPPV before we start because there are a myriad of different disorders that can cause vertigo or dizziness. BPPV, or benign paroxysmal positional vertigo, is the most common cause of vertigo and occurs because of the vestibular system. In the inner ear, there are semicircular canals that allow you to feel acceleration in different directions by housing little crystals called otoconia that move as the fluid in the inner ear moves. When you move forward, the fluid is pulled backwards and causes the otoconia to slightly lean, just like trees in the wind. However, when you have BPPV, those otoconia are loose within your ear and float around even when you aren’t moving. Those free-floating otoconia cause the sensation of spinning or moving even while lying in bed.
So, if you have BPPV, how can you tell? Here are some common activities that may trigger your vertigo throughout the day:
Rolling over in bed or getting out of bed
Tilting your head back while washing your hair
Bending down to garden or pick weeds
Sitting back in a dentist chair or hair salon chair
Bending down to tie your shoes
2. Is it Canalithiasis or Cupulolithiasis?
Canalithiasis will only last up to 60 seconds while Cupulolithiasis can last longer.
When you feel an onset of your vertigo symptoms, it should not last more than 60 seconds for the most common type of BPPV, canalithiasis. This is because those crystals or otoconia will move through a canal and eventually settle down due to gravity. While they are moving, you feel a sensation of spinning, but when they settle, that sensation goes away.
If your vertigo lasts longer, it may be caused by a different vestibular disorder or a special kind of BPPV called Cupulolithiasis. This type of BPPV is much rarer and occurs when crystals float from one part of the inner ear into another part and get stuck. If the crystals are stuck in the wrong place, tilting your head in a specific direction will cause gravity to pull them down. They then stay leaned over, causing a feeling of continuous vertigo instead of a short bout of vertigo.
3. The eyes are the window to your vertigo
So, if the vestibular system is in the inner ear, why do we want to look at the eyes? When you move through space, your eyes need to adapt so that everything isn’t blurry while you move. Your brain automatically adjusts your eyes to the movement that your vestibular system is sensing.
*Let’s try it* Put your finger about a foot and a half in front of your face. Now, focus your eyes on your finger and rotate your head side to side. You are able to focus on your finger without thinking to yourself, “Okay, eyes, when I turn my head to the left, you go right so we can keep looking at this finger.” It’s completely automatic!
When the vestibular system is not functioning correctly, it will tell the brain that the head is moving even when it isn’t. This will cause the brain to tell the eyes to adjust to the movement. The eyes will begin to twitch or beat in a specific direction even though the head isn’t actually spinning. This movement of the eyes is called nystagmus. Take a look at this video where I demonstrate how to provoke nystagmus!
Before we put all this information together, here’s a Vocab Recap:
Otoconia – the crystals that detect the movement of the fluid in your inner ears
Semicircular Canals – there are 3: posterior, anterior, and horizontal
Canalithiasis – crystals, or otoconia, are loose. Nystagmus lasts no longer than 60 seconds
Cupulolithiasis – otoconia were loose and are now stuck in the wrong place. Nystagmus will last for as long as the person’s head in a provocative position
Nystagmus – the beating of your eyes when your brain senses movement from your vestibular system, whether there actually is movement or not
4. The Dix-Hallpike: the gold standard for diagnosing BPPV
This test will help direct which treatment method will be appropriate for your BPPV. It is a simple change in position from sitting to lying on your back to sitting again to determine which canal those otoconia are loose in. The tester can determine which canal the loose otoconia reside by observing which direction your nystagmus beats. Btw, this test will reproduce vertigo and nausea, so you may want to keep a bucket close. It usually takes a trained professional to see these subtle eye movements but feel free to give it a shot at home but do not try to diagnose this yourself.
Here is a short explanation and demonstration of the test:
If your BPPV is a right posterior canal canalithiasis, your nystagmus will beat upward and with a right torsion during a right Dix-Hallpike test and will stop beating within 60 seconds. Upon returning to sitting from the supine (laying down) position, the nystagmus will beat in the opposite direction, downward and with a left torsion. Observing the eyes during both sit to supine and supine to sit will help to confirm the diagnosis. If you perform a left Dix-Hallpike on a person with right posterior canal canalithiasis, the nystagmus may be weaker or absent.
That was a lot of detail, so here’s a little summary chart:
Notice we didn’t talk about horizontal canal BPPV. This is because it is diagnosed with a couple of different tests such as the Roll Test, Bow and Lean, and Sit to Supine. These are very similar to the Dix-Hallpike but will provoke horizontal nystagmus.
Here’s a short video demonstrating this test:
Since it is a less common type of BPPV, we won’t go into too much detail. This condition is much rarer than the posterior canal BPPV, but the treatment for horizontal canal BPPV is called the BBQ Roll. Yes, that’s the real name of the maneuver.
So, now that you know which type of BPPV you have, the appropriate treatment can be determined. With this information, you won’t be in the dark about your vertigo anymore, and you can head forward in your healing process armed with knowledge and hope.
Let’s end with some information on your best shot at recovery.
5. Go to a balance clinic
If you’ve already gone to your primary care doctor and been prescribed Dramamine, also known as meclizine or antivert, don’t stop there. There are numerous causes of vertigo not mentioned in this article. It often requires more advanced instruments to diagnose and treat which are usually unavailable at your local family doctor’s office.
Here’s what you to search for:
On Google or Yelp, search “balance clinic” or “balance rehab.” This will bring you to a local clinic of physical therapists and/or physicians who will utilize these tests and many others to diagnose your vertigo. Give them a call to find out if you are an appropriate patient for them. They are highly specialized and usually undergo additional education to treat patients with vestibular conditions. At these clinics, there are many specialized instruments, one of which is called a computerized dynamic posturography (CDP). It is used to measure which balance system is functioning poorly. Balance clinics invest large sums of money in these instruments just so they can provide the correct, appropriate treatment for your recovery. Whether you are suffering from BPPV or another vestibular disorder, these are the healthcare professionals who can help.
Do not settle for a life of dizziness and nausea. If your vertigo is causing you to forfeit an active lifestyle or avoid certain activities you love, it’s not worth it to wait another day. I don’t work at a balance clinic, nor do I get any bonus for referring people to one, but I have had many patients who suffer from vertigo. It is incapacitating. There are experts who can help you and care about your vertigo. So go online, find your local clinic, and start your recovery today!