Benign Paroxysmal Positional Vertigo


This guidance covers benign paroxysmal positional vertigo (BPPV): recurrent severe rotational vertigo provoked by positional changes, not associated with hearing loss, tinnitus or headache. Each episode of vertigo lasts less than 30 seconds.

Out of scope

Other pathologies causing vertigo.


Signs and Symptoms

  • Associated with positional change
  • Brief or no latency following positional change
  • Nystagmus fatigues within 1 minute
  • Not necessarily associated with hearing loss or tinnitus
  • May experience rotary sensation

History and Examination

  • Hallpike's positional test is diagnostic
  • Otherwise normal examination of ears and cranial nerves

Differential Diagnoses

  • If Hallpike negative or atypical response consider other pathologies

Red Flags

Immediate, single plane or non fatiguing nystagmus in response to Hallpike indicates possible central pathology. Refer to ENT.


  • Epley manoeuvre

Referral Criteria

Refer to ENT if
  • Hallpike's negative or atypical (even if history suggests BPPV)
  • Epley manoeuvre unsuccessful
  • Epley manoeuvre not possible e.g. severe cervical spondylosis

Note - Patients may not be fit to drive themselves home after an Epley manoeuvre

Referral Instructions

e-Referral Service Selection

  • Specialty: Ear, Nose & Throat
  • Clinic Type: Balance/Dizziness
  • Service: DRSS-Eastern-Ear Nose and Throat-Devon CCG- 15N

Referral Forms

DRSS Referral forms

Supporting Information

How to do the Manoeuvres

Hallpike's video

Epley's video

Benign Paroxysmail Positional Vertigo

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: April 2017


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