Positonal vertigo?

Curious how many of you have/had vertigo that was always positional? As opposed to brought on by migraine triggers?

How do you distinguish the two?

You may be experiencing positional vertigo because of a trigger.


what i meant was, vertigo that comes on with certain head positions, not out of the blue?

I’ve had vertigo strike with certain head positions that was not BPPV, just migraine related junk. If it’s BPPV you will note discreet nystagmus – eyes pulsing towards the affected ear and then it will “fatigue” as you stop moving (the ear rocks stop moving).


Thanks Scott. I know that the nystagmus is used to detect BPPV but Buki et all presented a paper that showed a high percentage of BPPV’ers who went on to develop symptoms especially on arising who DID not get nystagmus

Hi D,

Can you post the ref please?

Thanks S

This is just a personal experience and I can’t speak for others, but when I’ve had positional vertigo due to BPPV it’s been exactly how Scott describes, and the vertigo ‘fatigues’ or fades off within about 30 seconds (regardless of whether you move your head out of the position or keep it held there). When moved into an extreme position, e.g. the Dix Hallpike position the nystagmus would be so severe I could feel my eyes jumping, and I could also feel the nystagmus if I turned over in bed, but interestingly I couldn’t feel it at all when I sat up or lay down in bed (although that still provoked some vertigo).

The difference with positional vertigo due to MAV (in my experience) is the timing element of it. It just doesn’t settle down in the same, quick way. If I moved my head in a way that provoked vertigo, then the vertigo would last until I moved my head out of that position. I’ve had a few attacks that have lasted for several hours, where the only position I could be free of vertigo was lying flat on my back with my head totally still. Luckily I’ve not had that for well over a year now…

So for me the difference really was that BPPV was horrible, but I could cope with it as it was transient, whereas the MAV positional dizziness was totally disabling (and involving a trip in an ambulance to A&E on one occasion when I was at work when it happened unfortunately!).

Hey Beech,

Interesting hearing your experience with BPPV. For me it was the opposite in that the vertigo I got with BPPV was far worse for me to tolerate than the MAV sort at its worst. BPPV attacks are the only ones where I have felt like I would throw up if I didn’t keep still. MAV has left me feeling nauseated but never have I really felt like I’d hurl my cookies. BPPV has struck only twice thankfully, both times when I rolled over in bed. It definitely does suck but it goes quickly too with the MEP and about a week of recovery.

Cheers 8)

Hi Scott,

I perhaps wasn’t very clear actually! The feeling of vertigo/sickness was exactly the same, i.e. presumably how you felt rolling over in bed. The difference when it was a MAV episode was in the timing. But even the MAV vertigo attacks were transient, despite lasting hours rather than seconds (BPPV). But when I had just BPPV I always recovered completely within a few days (like you are also saying), whereas MAV just set off all this crazy stuff, with a few repeated vertigo attacks (spaced out over the course of a few months), and then months and months of other stuff like feelings of false movement, feeling like I was moving slightly all the time, and also hypersensitivity to motion/visual triggers etc., which BPPV would never cause (or I don’t think so?). Once the MAV vertigo attacks were out of the way the residual MAV stuff was unpleasant and annoying, but I could tolerate it and manage my normal day-to-day life ok, even though it made me pretty miserable struggling through. It’s the vertigo that does it for me, it’s just totally disabling!

Anyway, I am lucky as I am not too bad these days. I’ve not had full blown vertigo for well over a year now :smiley:

Sure Scott:


Interesting hypothesis: Type 2 BPPV

— Begin quote from ____

We suggest that sBPPV is more common than anticipated. Type 2 BPPV may be identical with sBPPV or constitute a major subgroup of it. For a definition of Type BPPV, we suggest the following: (1) complaints suggesting BPPV (short episode of vertigo when bending forward, lying down, sitting up or turning over in bed); (2) no nystagmus during either DixeHallpike positioning or supine roll to the left and right; and (3) a short episode of vertigo during and immediately after sitting up from the a DixeHallpike position. We did not find any patients with sBPPV complaints who could not be assigned to the group with Type 2 BPPV. Nevertheless, we prefer to leave open the possibility that mechanisms other than chronic short-arm canalolithiasis may cause sBPPV. We suggest that the introduction of Type 2 BPPV as a valid differential diagnosis of patients with positioning vertigo will lead to better classification and therapy in numerous cases.

— End quote

Professor Halmagyi here in Sydney had this to say about this paper (note Halmagyi has done extensive research himself into BPPV and invented the Head Impulse test):

"Of course, the explanation is rather fanciful and not directly provable, but then so are most of the explanations given for the various varieties of BPPV. Nonetheless, the practical fact remains that whatever might be the flaws in all these post-hoc explanations, repositioning treatment for BPPV is so effective that those clinicians who have mastered it can (at least where I live) expect a steady supply of jam and cake from grateful little old ladies. Büki et al claim similar rate of remission from this chronic BPPV with what is in effect a modified Brandte–Daroff manoeuvre – repetitive sit-ups from the head-hanging position (extra benefits for the corpulent).

This, in short, is the take-away message for those of us having to deal with chronically dizzy patients late on a Friday afternoon. If the patient does not have vertigo or nystagmus in the DixeHallpike position, but does have vertigo during and after coming up from either the left or the right side, with, but even if without, noticeable retropulsion, then this patient could have Type 2 BPPV (short-arm posterior canalolithiasis) and should spend the weekend trying repeated DixeHallpike manouevres from the symptomatic side and then come and see you again on Monday, Tuesday at the latest. Much more useful than ordering an MRI."

Scott 8)