Benign Paroxysmal Positional Vertigo (BPPV)
What is BPPV?
Benign Paroxysmal Positional Vertigo (BPPV) is described as the sudden onset of vertigo, that is caused by certain movements of the head. The sensation of vertigo is the external experience of rotational or spinning movement, and it occurs without input from the external environment. Amongst patients who present with vertigo symptoms, 17-42% of them will be diagnosed with BPPV, as will between 11-64/100,000 people in Brisbane each year . BPPV is easily diagnosed after a history of your symptoms and is confirmed with physical tests, it will rarely require any further investigation [1, 2]
BPPV is a condition affecting the otolith organs inside your inner ear. These otolith organs are designed to detect the gravitational and acceleration forces in our head during movement, so that we can adjust and stay upright. When these organs become impaired, they will detect movements, that are normally fine, and react by causing symptoms of vertigo. This lower threshold for quite severe symptoms of vertigo can be quite debilitation for sufferers of BPPV .
What are the symptoms of BPPV?
- Nystagmus (rapid, unidirectional beating of the eyes, unnoticed by the patient)
Chronic Tension Type Headache
Chronic tension type headache is classified as headache pain being bilaterally on both sides of the head, where pain is usually symmetrical and equal from left to right. Compared to migraines, chronic tension type headache causes mild to moderate pain, and feels more of a tightening and pressing sensation rather than a pulsating pain.
What Causes BPPV?
Both of the main theories about the cause of BPPV regard changes in the endo-lymph that flows in the semi-circular canals if the otolith organs. The first theory is the ‘cupulolthiasis model’ that suggests that loose matter in the endo-lymph becomes stuck in the capuli, or the sensory organs that are located in the otolith. The second theory is the ‘canalithiasis model’ which suggests that the capuli detect free-flowing particles in the endo-lymph. The abnormal detections in both of these theories is what would trigger abnormal sensations of vertigo .
There are two physical tests that can be used to accurately diagnose BPPV. The Dix-Hallpike Test can be used to detect dysfunction in the posterior canal of the otolith, while the supine roll test can be used to assess the horizontal canal. In positive tests; the patient will experience their symptoms of vertigo, and the therapist will observe for signs of nystagmus, or rapid beating of the pupils. In the rare case that the superior semi-circular canal is affected, the Dix -Hallpike test would be positive and the therapist will observe an upward beating nystagmus [2, 1].
A lot of the patients that we see will experience all of the symptoms of BPPV, but the results of their physical tests are unclear, or treatment isn’t as effective as expected. In these cases, it is likely that increased sensitivity in their brainstem is the true cause of their symptoms. The vestibular nerve will send ‘normal’ information to this hyper-sensitive brainstem that is interpreted as a threat, causing the patient to experience vertigo.
I’ve tried it all, is there anything else that can help my BPPV?
The gold-standard treatment for the most common type of BPPV, posterior canal, is the Epley Manoeuvre . This technique places the patients head in a series of different positions, placing shifting matter and endo-lymph through the semi-circular canals. The Epley Manoeuvre is commonly taught to patients to be performed regularly at home.
The patients that we see at Brisbane Headache & Migraine Clinic have often had mixed results with the Epley Manoeuvre, have tried various medications and some have even tried surgical intervention. They sometimes have mild results, but it is often short-lived. This is because they often haven’t been thoroughly assessed to determine if a sensitised brainstem is the true cause of their symptoms.
If we assess you and can determine that, yes, the brainstem and upper cervical spine are the true cause of your BPPV then we can start treatment right away. Our modern, world-leading techniques are safe, gentle, medication-free and non-invasive, and we expect to see positive results within the first 6 sessions, as we do with 85-90% of our patients.
Hemicrania continua is usually a more severe headache that typically affects one side of the head. The headache does not shift from side to side, and is usually locked on one side unilaterally. This headache is present all the time with no pain free periods. Pain is usually a moderate pain in nature, however tends to have severe spikes of pain throughout the day. People who suffer from this headache may also experience autonomic features such as a watery eye, swollen or droopy eye-lid, redness in the eye, block or runny nose. Migraine like symptoms can also occur such as sensitive to light, sound or smell, nausea and vomiting.
|||P. You, R. Instrum and L. Parnes, “Benign Paroxysmal Positional Vertigo,” Laragyscope Investigative Otolaryngology, vol. 4, no. 1, pp. 116-123, 2019.|
|||H. Tang and W. Li, “Advances in the diagnosis and treatment of benign paroxysmal positional vertigo,” Experimental and Therapeutic Medicine, vol. 14, no. 3, pp. 2424-2430, 2017.|
|||D. Watson and P. Drummond, “Cervical Referral of Head Pain in Migraineurs: Effects on the Nociceptive Blink reflex,” The Journal of Head and Face Pain , vol. 54, no. 6, pp. 1035-1045, 2014.|
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1. Saper, JR. The mixed headache syndrome: a new perspective. Headache Disorders: Current Concepts in Treatment Strategies. Littleton, MA: Wright-PSG Publishers, 1983; 22:284-286.
2. Saper, JR, Silberstein SD, Godeon CD, Hamel RL.. Handbook of Headache Management: A Practical Guide to Diagnosis and Treatment of Head, Neck, and Facial Pain. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 1999.
3. Bartsch T, Goadsby PJ. Stimulation of the greater occipital nerve (GON) enhances responsiveness of dural responsive convergent neurons in the trigeminocervical complex in the rat. Cephalalgia. 2001;21:401-402.
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