Positional vertigo

Positional vertigo is one of the most common forms of vertigo and typically occurs when the head is moved into a certain position. Those affected experience sudden, brief episodes of spinning vertigo, which, although very unpleasant, are usually harmless. The correct medical term is benign paroxysmal positional vertigo, which means a benign form of vertigo that occurs in episodes. The good news is that this form of vertigo is easily treatable and can often be successfully managed with simple positional manoeuvres.

What exactly is positional vertigo

Positional vertigo is a type of vertigo that occurs briefly after the head is moved into a certain position. The attacks are episodic and can feel like suddenly being on a merry-go-round. Although the symptoms are harmless, those affected find them extremely unpleasant and sometimes even frightening. The vertigo originates in the vestibular system of the inner ear and is caused by a problem there.

In this context, the term ‘benign’ means that there is no serious or dangerous underlying condition. The word ‘episodic’ describes the fact that the vertigo occurs suddenly and in attacks. Unlike other forms of vertigo, which can last longer, positional vertigo is characterised by attacks that are brief and subside after a few seconds to a maximum of one minute.

Difference from other forms of vertigo

It is important to distinguish positional vertigo from other forms of vertigo. In so-called postural vertigo, for example, the dizziness persists as long as the head remains in the triggering position. In positional vertigo, however, the symptoms occur immediately after a change in position and then subside quickly, even if the position is maintained. This distinction can be important for the correct treatment.

The vestibular system and its function

To understand how positional vertigo arises, it helps to look at the vestibular system. This is located in the inner ear and is responsible for detecting changes in position and body movements. It consists of three semicircular canals, which are oriented in different directions and register rotational movements. In addition, there are two small sacs that provide information about linear movements and gravity.

These sacs contain tiny crystals of calcium carbonate, also known as otoliths. These crystals are normally firmly embedded in a membrane and help to detect movement. If these crystals become dislodged and enter the semicircular canals, positional vertigo occurs. The connection between balance and the ear is complex and important for many bodily functions.

Causes and development

Benign paroxysmal positional vertigo occurs when the small crystals detach from the vestibular system. These otoliths then enter the semicircular canals, where they do not normally belong. When the head moves, these crystals also move within the fluid of the semicircular canals. This movement of the crystals creates a suction effect that stimulates the sensitive sensory cells in the semicircular canal.

The problem is that the brain now receives conflicting information. The affected ear reports movement, whilst the other ear and the eyes signal something else. The brain cannot process these conflicting signals correctly, resulting in a sensation of dizziness. The posterior semicircular canal is usually affected, as this is where the crystals are most likely to end up due to gravity.

Why do the crystals become dislodged?

In most cases - around 90 per cent of those affected - it remains unclear exactly why the crystals become dislodged. Positional vertigo then appears to occur spontaneously, without any specific cause being apparent. However, there are known risk factors that can contribute to the crystals becoming dislodged. These include head injuries or traumatic brain injuries, following which the crystals may become loose.

Inflammation of the inner ear or ear surgery can also cause the crystals to dislodge. Certain pre-existing conditions such as Meniere’s disease or migraine also appear to increase the risk. Prolonged bed rest, for example following surgery or a serious illness, can also be a triggering factor, as the lack of movement means the crystals are not held in their normal position.

Age-related and other risk factors

The risk of positional vertigo increases with age. This may be linked to age-related changes in the inner ear. Osteoporosis, a condition in which bones lose density, is also discussed as a possible risk factor. A vitamin D deficiency could also play a role, as vitamin D is important for calcium metabolism and the crystals in the ear are made of calcium carbonate.

Women are affected by positional vertigo about twice as often as men, although the reasons for this are not fully understood. The peak incidence is between the ages of 40 and 70, although younger people can also be affected. It is estimated that approximately one in 40 people may experience positional vertigo at some point in their lives.

Typical symptoms and complaints

The main symptom of positional vertigo is a sudden onset of severe spinning vertigo. Those affected often describe the sensation as being on a merry-go-round or as if everything around them is spinning. This vertigo typically occurs only with certain movements. These can include lying down in bed, getting up in the morning, turning from one side to the other, bending forward or tilting the head back.

The good news is that the attacks are short-lived. They typically last from a few seconds to a maximum of one minute, and usually less than 30 seconds. As soon as the head is kept still in the new position, the vertigo subsides quickly. This is an important distinguishing feature from other forms of vertigo, which can last longer.

Accompanying symptoms

In addition to the vertigo itself, other unpleasant accompanying symptoms may occur. Those affected often report nausea, which in some cases can be so severe that it leads to vomiting. Sweating and a general feeling of unease are also typical. Many people experience feelings of anxiety during the attacks, as the sudden, intense sensation of vertigo can be perceived as very threatening.

After the attacks, a feeling of unsteadiness may remain. Those affected sometimes describe this as walking on cotton wool or as if the ground were not firm beneath their feet. This unsteadiness can last for a few minutes or even longer, even after the actual vertigo has subsided. In rare cases, tinnitus may also occur, although this is not one of the typical symptoms of positional vertigo.

Impact on daily life

Although the individual episodes of vertigo are brief, they can significantly disrupt daily life. Many sufferers develop avoidance behaviours to prevent the unpleasant episodes. They avoid certain movements, turn carefully or stand up only slowly. Some people no longer dare to change position in bed, or sleep only in a semi-sitting position.

This avoidance behaviour can lead to further problems. The restricted mobility can cause tension in the neck and back. Psychological consequences such as anxiety or depressive moods can also arise if quality of life is severely restricted by the vertigo. Particularly in older people, the fear of falling can lead to them moving less and less, thereby becoming less steady overall.

How is positional vertigo diagnosed

The diagnosis of positional vertigo begins with a detailed consultation. Doctors ask about the exact symptoms, when and how the vertigo occurs, and how long it lasts. Possible triggers or pre-existing conditions are also discussed. This information is already very important, as the typical description of the symptoms often provides a strong indication of positional vertigo.

Special tests are then carried out to confirm the diagnosis. The most important test is the so-called Dix-Hallpike manoeuvre. In this test, the patient first sits upright, their head is turned to one side, and then they are quickly brought into a supine position, with the head slightly hyperextended backwards. This movement is designed to specifically trigger the vertigo.

Observation of eye movements

During the test, the examiner closely observes the eyes. With positional vertigo, typical, involuntary eye movements occur, known as nystagmus. These eye movements are jerky and follow a specific pattern. It is important to note that these movements do not occur immediately, but only after a brief delay of a few seconds, and that they then quickly subside and disappear.

Sometimes special glasses, known as Frenzel glasses, are used for the examination. These glasses prevent the patient from fixing their gaze on a fixed point, which makes it easier to observe the eye movements. Depending on which manoeuvre triggers the vertigo and what the eye movements look like, specialists can determine which of the three semicircular canals is affected.

Further investigations if necessary

In most cases, the medical history and positional tests are sufficient to make a diagnosis. However, if there is any doubt or the symptoms are atypical, further investigations may be necessary. This is particularly important to rule out other, potentially more serious causes of the vertigo. These may include hearing tests, balance tests or, in rare cases, imaging procedures such as magnetic resonance imaging.

Treatment using positional manoeuvres

The good news is that positional vertigo is very treatable. The treatment involves moving the displaced crystals from the semicircular canals back to their original position. This is achieved through specific movements known as positional manoeuvres or repositioning manoeuvres. The success rate of this treatment is high, at up to 90 per cent.

The manoeuvres use gravity to guide the crystals out of the semicircular canals through specific head movements. The crystals are intended to return to the two sacs of the vestibular system, where they belong and cause no harm. The treatment is not painful, but may trigger brief episodes of vertigo whilst being performed, as the crystals are being moved.

The Epley manoeuvre

The Epley manoeuvre is one of the most commonly used treatment methods. It begins in a sitting position, with the head turned towards the affected side. The person is then quickly moved into a supine position, with the head slightly hyperextended and turned to the side. After about 30 seconds, the head is turned to the other side, and finally the person rolls onto that side, looking downwards.

Each position is held for about 30 seconds to allow the crystals time to move. At the end, the person is slowly returned to a sitting position. The entire manoeuvre takes a few minutes and is carried out by specialists. It is important that there is no pillow under the head during the manoeuvre, as this could hinder the movement of the crystals.

Other treatment methods

In addition to the Epley manoeuvre, there are other effective methods. The Semont manoeuvre involves a faster, more vigorous movement from one side to the other. The Brandt-Daroff manoeuvre is particularly suitable for self-treatment at home, as it is easier to perform. Depending on which semicircular canal is affected, special manoeuvres such as the Barbecue manoeuvre or the Gufoni manoeuvre may also be used.

The choice of the right manoeuvre depends on which semicircular canal is affected. The posterior semicircular canal is most commonly affected, followed by the horizontal and anterior semicircular canals. Specialists can determine which manoeuvre is most suitable based on the examination results. As a rule, the manoeuvres are performed several times in succession to increase the chances of success.

Self-treatment and exercises for home

Following a medical diagnosis and thorough instruction, the positioning manoeuvres can also be carried out at home. This is particularly helpful if the symptoms recur or if mild symptoms persist after the initial treatment. Although self-treatment has a slightly lower success rate than treatment under therapeutic supervision, it can serve as a useful supplement.

It is important to use only the manoeuvre recommended by a doctor. Incorrect movements could worsen the situation or dislodge the crystals into a different semicircular canal. The exercises should be performed several times a day, for example three times in a row or five times in the morning. Care should be taken to ensure a soft surface is used, and it is advisable to have someone nearby in case dizziness occurs.

Guidelines following treatment

After performing a repositioning manoeuvre, there are a few recommendations to ensure success. Some specialists recommend sleeping with your head elevated on the first night after treatment, for example using two pillows. Rapid head movements should also be avoided in the first few days. However, these recommendations are not universally agreed upon by all experts, and many do not consider them strictly necessary.

Generally speaking, it is important not to restrict yourself too much. Normal everyday movements are permitted and even advisable. Excessive rest can lead to the crystals becoming dislodged again or the dizziness becoming more persistent. Most people can resume their normal activities shortly after treatment, but should be a little more cautious in the first few days.

Medicines and other treatment options

Medication plays a minor role in the treatment of positional vertigo. It cannot influence the cause - namely the displaced crystals - and is therefore not suitable for treating the underlying condition. In some cases, however, medication for nausea or vertigo may be used in the short term, particularly if the symptoms are very severe or vomiting occurs.

These medicines, which include antihistamines or specific anti-vertigo agents, should only be taken for a short period. Long-term use is not advisable and may even be harmful, as it can hinder the natural adaptation of the vestibular system. The medicines are intended solely to relieve symptoms and should not replace treatment with repositioning manoeuvres.

Surgical treatment in exceptional cases

In very rare cases, affecting less than one per cent of those affected, surgery may be considered. This is only an option if all other treatment methods have failed and the symptoms are severely impairing the patient’s quality of life. During surgery, the affected semicircular canal may be closed off or its nerve supply severed. However, this leads to a permanent impairment of the balance organ’s function and should therefore really only be considered as a last resort.

Course and prognosis

The prognosis for positional vertigo is generally good. The condition is harmless and often resolves on its own without treatment. Around half of those affected are symptom-free within three months, even without treatment. The crystals may return to the correct position on their own or dissolve. Nevertheless, the vertigo can persist for months or even years without treatment, which is why early intervention is recommended.

Following successful treatment with repositioning manoeuvres, most people are symptom-free immediately or within a few days. In some cases, a slight feeling of unsteadiness may persist for a few days until the vestibular system has fully adjusted. This sensation usually disappears on its own and may even resolve more quickly with normal movement and activity.

Relapses and recurrence

An important point to note is that relapses are not uncommon in positional vertigo. In around 30 to 50 per cent of those affected, the symptoms recur within two years. The probability of a relapse within five years is estimated at around 30 to 35 per cent. The reasons for these relapses are not fully understood; it is thought that crystals may detach again.

The good news is that people who have already been successfully treated can often perform the repositioning manoeuvres themselves if the symptoms return. Appropriate training by specialists is helpful in this regard. Many people feel more confident knowing that they can take action themselves in the event of a relapse. Nevertheless, medical advice should always be sought if there is any uncertainty or if self-treatment does not help.

Risks and complications

Although positional vertigo itself is harmless, it can have indirect consequences. The greatest risk is an increased risk of falling. If a vertigo attack occurs whilst standing up or walking, this can lead to a fall. Such falls can result in serious injuries, particularly in older people. The fear of falling can, in turn, lead to those affected moving less, which brings with it further problems such as muscle wasting and unsteadiness when walking.

The avoidance behaviour triggered by dizziness can severely limit quality of life. If people avoid certain movements for fear of dizzy spells, lie in bed cautiously or hardly dare to move their head, this can lead to tension. Constant tension and worry can also be stressful and lead to sleep disturbances or exhaustion. The increased risk of falling associated with balance problems is a significant concern.

Psychological effects

The psychological consequences of positional vertigo should not be underestimated. The sudden, intense sensation of dizziness can be very frightening. Some people develop a genuine fear of the attacks, which can lead to phobias. These fears can take on a life of their own and persist even after the actual vertigo has been treated.

In cases of prolonged or frequently recurring symptoms, depressive moods may also occur. The reduced quality of life, the uncertainty in daily life and the feeling of helplessness can be distressing. In such cases, it may be helpful to seek psychological support in addition to physical treatment. Relaxation techniques such as progressive muscle relaxation or breathing exercises can also be helpful in managing anxiety.

Tips for daily life with positional vertigo

Until treatment takes effect or in the event of relapses, there are some practical tips that can make daily life easier. Slow, deliberate movements can help prevent or alleviate dizzy spells. When getting out of bed, it is advisable to sit on the edge of the bed first and wait a moment before standing up. Turning over in bed should also be done slowly and carefully.

It can be helpful to make your surroundings as safe as possible. Tripping hazards should be removed, slippery floors avoided and there should be sufficient lighting. Grab rails in the bathroom or next to the bed can provide additional safety. If you feel unsteady when walking, a walking stick can offer support. However, it is important not to restrict yourself too much, as normal movement is important for the vestibular system.

When to seek medical help

Although positional vertigo is harmless, there are situations in which medical advice is important. If dizziness occurs for the first time, a medical examination should always be carried out to confirm the diagnosis and rule out other causes. Even if the symptoms differ from the typical characteristics - for example, if the dizziness lasts longer than a minute, is continuous, or is accompanied by hearing problems, headaches or neurological deficits - a medical assessment is necessary.

Professional help should also be sought in the event of very severe or frequent episodes of vertigo that significantly impair quality of life. Even if self-treatment with repositioning manoeuvres does not help or the symptoms return very quickly after treatment, a follow-up consultation is advisable. In some cases, a specialist examination at a vertigo clinic or by ear, nose and throat specialists may be necessary.

Prevention and long-term outlook

Unfortunately, there is no sure-fire way to prevent positional vertigo, as the exact causes often remain unclear. Nevertheless, certain measures may help reduce the risk. An adequate intake of vitamin D and calcium could be important, as these substances play a role in bone metabolism and possibly also in the stability of the crystals in the ear. Regular exercise and avoiding prolonged bed rest may also be beneficial.

For people who have already experienced positional vertigo, it may be helpful to perform the exercises they have learnt occasionally as a preventive measure. Some specialists recommend doing the Brandt-Daroff exercises regularly to train the vestibular system and possibly prevent relapses. However, there is no clear evidence that this is truly effective.

Long-term outlook

For most people with positional vertigo, the long-term outlook is very good. Although relapses can occur, the condition is generally well managed. With increasing age, the vestibular system can generally deteriorate slightly, which may lead to an increased susceptibility to vertigo. However, regular exercise and an active lifestyle can help to train the vestibular system and maintain stability.

It is important to know that positional vertigo is not a progressive condition and does not lead to permanent damage to the vestibular system. Following successful treatment, the vestibular system is fully functional again. Although the symptoms are unpleasant, there is no need to worry about long-term consequences. With the right treatment and, where necessary, a little patience, most people can lead a normal, active life without being restricted by vertigo. Quality of life in old age can be influenced by various factors, and well-being should always be the focus.