Updated June 19, 2018
When I tell a patient they are dizzy because of loose crystals in their head, many of them are skeptical, to say the least.
But then I tell them I can treat it effectively with no expensive scans or tests. They won’t need surgery or medications. They just need a 30-minute visit in my office.
That’s what really turns their heads, so to speak.
Loose crystals in the head?
As we’ve discussed previously in this blog, it’s true.
Benign paroxysmal positional vertigo (BPPV) is the most common type of vertigo. And, as strange as it may sound, it is caused by tiny calcium carbonate crystals — otoconia — becoming dislodged from a small organ called the utricle within the chambers of your inner ear.
The body’s balance system — also known as the vestibular system — is, literally, finely balanced. The slightest anomaly can have hugely disproportionate effects.
If fragments of otoconia accumulate in one of your balance canals, they can cause a kind of micro-turbulence of the canal’s fluid, which is normally static if your head is not moving. As a result, your inner ear sends a false signal to the brain that you are moving, and your brain adjusts your eye position to compensate. However, since you’re not really moving, this unnecessary eye movement results in vertigo. Additional contradictory sensory information from vision and other sensors of body position make the experience even worse.
Fortunately, the sensation is brief, and it is only triggered when you put your head in a position such that the dislodged otoconia succumb to the effect of gravity.
This is an example of both the beauty and the delicacy of the human balance system. And it’s also how a skilled caregiver can easily fix BPPV.
An ounce of cure
There is a proven therapy for most presentations of BPPV. It’s been around for over 20 years. Practically any trained provider can administer the treatment: a primary care physician, a nurse practitioner, a trained physical therapist, or a specialist like an audiologist or an otolaryngologist.
Called the Epley maneuver, its objective is deceptively simple: to cause the otoconia to go back where they belong. The maneuver relocates them from the balance canal back to their gelatin membrane in the utricle, using gravity to nudge them along.
The technique for accomplishing this is to find the position, the movement, or the particular head angle that triggers an attack, in order to identify which ear and balance canal is affected. Once this is determined, a series of head movements can be used to enlist gravity to help the otoconia find their way home.
There are two important things you should know about this approach to curing BPPV:
- The Epley maneuver almost never fails. And if the vertigo does recur, we can usually just repeat the procedure and it will almost certainly work again.
- Even though BPPV is easy to diagnose and easy to treat with the Epley maneuver, some doctors may be overhasty in ordering expensive imaging scans and blood tests for their vertigo patients, and they may prescribe medications like meclizine that treat the nausea and vomiting caused by motion sickness but do little or nothing to address the root cause of the problem.
Granted, not all vertigo is BPPV, and there are other conditions that resemble BPPV and may require more in-depth evaluation. However, BPPV is the most common type of vertigo, and it can be readily diagnosed by a trained provider. The symptoms are clear, repeatable and predictable. In classic BPPV, the patient feels fine until you put them in the trigger position, and then they get vertigo. It typically lasts for less than a minute, and if you keep repeating the move, the vertigo “fatigues,” meaning it diminishes in both severity and duration.
It bears repeating that we know how to treat BPPV mechanically. Surgical options are only considered in rare circumstances. And yet, some patients undergo unnecessary tests and are prescribed medications which have not been established as effective for use in treating BPPV.
An ounce of prevention is worth a pound of cure. But an ounce of cure is usually better than a pound of cure when it comes to BPPV.
A final thought
BPPV is not a life-threatening disease. That’s why the first letter—“B”—stands for benign.
But the next letter—“P” for paroxysmal—makes it very serious to the sufferer. The attacks are sudden, intense, and often come with no warning. It’s an alarming, even frightening experience. Some people think they’re having a stroke the first time it happens.
One physical sign, nystagmus, also goes by the name “dancing eyes.” The eyes rotate in the head involuntarily, as the brain adjusts them for a head movement which is not occurring. If you’re not a healthcare professional, having never witnessed it, and you see your loved one lying on the exam table with their eyes rotating slowly in their head, it can be disconcerting.
But again, we can do something about it.
We know how to treat BPPV. Treatment maneuvers for BPPV resolve the symptoms at a rate of 90% or more after one to three treatments. In addition, symptoms may decline spontaneously as the brain finds ways to adjust over time to the abnormal signals received from the balance system.
If you or a loved one are struggling with dizziness, contact the Swedish Balance Center, part of the Swedish Neuroscience Institute. Our interdisciplinary team provides a wide range of neurological services to patients with balance problems, including all forms of vertigo, guided by our Mission to improve the health and well-being of each person we serve.
This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.