BPPV (Benign Paroxysmal Positional Vertigo)

What is BPPV??
BPPV attacks occur in short episodes of vertigo provoked by positional changes such as lying down, turning over in bed, looking up or bending over. Typically, the BPPV attacks will last less than a minute. BPPV is caused by the presence of calcium carbonate crystals within the Semi-Circular Canal of the inner ear.

How is BPPV diagnosed?
Positional tests specific for each canal help diagnose BPPV. MRI, CT scan and routine blood tests are useless to diagnose BPPV.

How is BPPV treated?
Positional manoeuvres, such as the Epley manoeuvre can help cure BPPV affecting the posterior canal Medication therapy and other non-specific vestibular exercises such as Cooksey-Cawthorne exercises and Brandt-Daroff exercises will not help get rid of BPPV

What is vestibular migraine?
Vestibular migraine is characterised by recurrent attacks of dizziness/vertigo and unsteadiness. The attacks can last from a few seconds to days. The vestibular symptoms can occur with or without headaches. Other symptoms that are present along with vestibular symptoms are hypersensitivity to bright lights, loud noises and motion intolerances.

How is vestibular migraine diagnosed?
There are no specific tests to diagnose vestibular migraine. Additionally, vestibular migraine can mimic BPPV, recurrent vestibulopathy, Meniere's disease and even a stroke, making it a chameleon in vestibular disorders. Therefore, these vestibular conditions should be ruled out first. Additionally, ICHD-3 vestibular migraine diagnostic criteria can help diagnose VM.

How is vestibular migraine treated?
Vestibular migraine will require a combination of food and lifestyle modification, vestibular physiotherapy and medication if necessary.

What is labyrinthitis?
Labyrinthitis = Inflammation of the labyrinth
Labyrinthitis is characterised by vertigo/dizziness, nausea, vomiting and unsteadiness resulting in vestibular hypofunction.Additionally, hearing loss will also be present in labyrinthitis. The acute symptoms can last for a few days to a week. If left untreated, the symptoms can persist for weeks to months and even years for some patients.

How is labyrinthitis diagnosed?
Labyrinthitis can be diagnosed by carrying out the following special tests Nystagmus analysis- Unidirectional nystagmus Head Thrust Test

How is labyrinthitis treated?
Acute phase - Medication and Vestibular physiotherapy Sub-acute /Chronic- Vestibular physiotherapy Long-term use of medication should be avoided as it can interfere with natural recovery and could cause issues such as Parkinsonism.

What is vestibular neuritis?
Vestibular Neuritis= Inflammation of the vestibular nerve The hearing will not be affected in vestibular neuritis Vestibular neuritis is characterised by vertigo/dizziness, nausea, vomiting and unsteadiness resulting in vestibular hypofunction. The acute symptoms can last for a few days to a week. If left untreated, the symptoms can persist for weeks to months and even years for some patients.

How is vestibular neuritis diagnosed?
Vestibular neuritis can be diagnosed by carrying out the following special tests Nystagmus analysis- Unidirectional nystagmus Head Thrust Test

How is vestibular neuritis treated?
Acute phase - Medication and Vestibular physiotherapy Sub-acute /Chronic- Vestibular physiotherapy Long-term use of medication should be avoided as it can interfere with natural recovery and could cause issues such as Parkinsonism.

What is visual dependency & Visual Vertigo?
People with visual dependency /visual vertigo, suffer from dizziness and unsteadiness due to lack of vision or challenging visual environments such as busy supermarkets, cinemas and scrolling mobile screen.

How visual dependency /visual vertigo is diagnosed?
Subjective history and balance tests can help ascertain if someone is suffering from visual dependency /visual vertigo

How visual dependency /visual vertigo is treated?
Customised balance retraining and habituation exercises will help reduce the visual dependency and visual vertigo

What is PPPD?
PPPD is a functional vestibular disorder, characterised persisting vestibular symptoms triggered /aggravated by certain movements, visual entertainments and certain postures.

How PPPD is diagnosed?
No specific tests to diagnose PPPD, however, focusing on the persisting nature of the symptoms, the triggers and aggravating factors such as movements, posture and environments can help diagnose it

How PPPD is treated?
PPPD is a complex condition and it is treated with vestibular physiotherapy, medication therapy and counselling

What is cervicogenic dizziness?
The neck proprioception, like vision and vestibular, is an integral part of the balance control mechanism. Therefore, issues affecting the neck, such as arthritis, can cause dizziness (cervicogenic dizziness) Similarly, dizziness due to vestibular disorders can cause neck stiffness to reduce the dizziness provoking head movements. This too could result in both neck pain.

How is cervicogenic dizziness diagnosed?
There are no specific tests to diagnose cervicogenic dizziness. Therefore, before making a diagnosis of cervicogenic dizziness, vestibular causes of dizziness such as BPPV & vestibular hypofunction should be ruled out.

How is cervicogenic dizziness treated?
Routine neck physiotherapy can help reduce the dizziness in cervicogenic dizziness. However, balance issues might need specific treatments.

Can stroke cause dizziness?
Certain strokes, such as posterior circulation stroke, can cause vertigo/dizziness due to the involvement on brainstem and cerebellum

How posterior circulation stroke is diagnosed?
MRI brain is routinely used to diagnose the stroke. However, HINTS test is reported to sensitive and specific to diagnose the posterior circulation Stroke

How dizziness in posterior circulation stroke is treated?
Customised vestibular physiotherapy and balance retraining can help reduce the dizziness/vertigo and improve balance in stroke patients with vestibular symptoms

What is the risk of falls in patients with dizziness?
Certain strokes, such as posterior circulation stroke, can cause vertigo/dizziness due to the involvement on brainstem and cerebellum

How is the risk of falling identified in patients with dizziness?
The risk of falling is identified by validated questionnaires and physical /balance tests

How is the risk of falling treated in patients with dizziness?
To reduce the risk of falling, firstly, the underlying cause of the dizziness should be correctly diagnosed and treated. Additionally, customised balance exercises and other multifactorial interventions could help reduce the risk of falling

What is Post-Concussion dizziness?
Both direct or indirect head trauma could cause vestibular symptoms such as vertigo, dizziness and unsteadiness along with other symptoms due to concussion /mild TBI. Patients with a concussion could suffer from peripheral vestibular conditions such as BPPV, vestibular hypofunction, PPPD and vestibular migraine etc.

How is a post-concussion vestibular disorder diagnosed?
Specific conditions such as BPPV and hypofunction are diagnosed with relevant bedside tests. Conditions such as PPPD and VM are diagnosed based on the history and validated diagnostic criteria.

How is post-concussion vestibular disorder treated?
To reduce the risk of falling, firstly, the underlying cause of the dizziness should be correctly diagnosed and treated. Additionally, customised balance exercises and other multifactorial interventions could help reduce the risk of falling

What is vertigo?
Vertigo is a false sensation of room-spinning/head-spinning sensation. Vertigo is merely a symptom, it is not a clinical condition. Vertigo is present in most vestibular disorders such as BPPV, labyrinthitis, vestibular neuritis and vestibular migraine. However, it can be occasionally present in non-vestibular conditions as well

How is vertigo diagnosed?
As noted above, vertigo is a symptom that is present in a range of conditions. Therefore, the underlying conditions should be looked at specifically to diagnose the cause of vertigo. Please check “Conditions We Treat”

How is vertigo treated?
Symptomatically, vertigo is treated with medications. However, this is an ineffective approach as it does not target the underlying issues. For effective therapy, underlying conditions need to be diagnosed first.

What is Motion Hyper sensitivity?
Motion Hypersensitivity (MHS) is a functional vestibular disorder, usually, it occurs as a secondary consequence of underlying vestibular/non-vestibular conditions such as vestibular migraine, vestibular hypofunction and BPPV etc.

How is Motion Hyper sensitivity diagnosed?
MHS is tested by carrying out dizziness-inducing head and body movements. Positional movements such as Brandt-Daroff or Motion Sensitivity Quotient (MSQ) can help establish it.

How is Motion Hyper sensitivity treated?
Exercises involving head and body movements are customised to create habituation. Gradually, the habituation exercises are progressed from simple to complex exercises.