I had an interesting day today because I resolved two cases of BPPV without nystagmus, or symptomatic BPPV.
I want to share with you a question both of the patients asked me during our private sessions.
Both of the patients I saw had BPPV, but had previously been told by other healthcare providers that they did not have BPPV.
The reason why they were told that is because they did not have any visible involuntary eye movement, which is called “nystagmus,” in the BPPV testing position.
Vertigo Detective Vocabulary Builder:
Nystagmus = involuntary eye movements
Many healthcare providers who rely solely on the common literature related to BPPV will tell the patient that if there is no observable nystagmus, then they do not have BPPV. If the patient gets symptoms during the BPPV test, they often explain to the patient that they are experiencing symptoms caused by a “conditioned response.”
Years ago, when I attended the first offering of the Advanced Vestibular Rehabilitation course offered by the Neurological Specialty Section of the American Physical Therapy Association, I learned for the first time about “symptomatic BPPV.”
Symptomatic BPPV is when patients have symptoms in the BPPV test position but do not have any corresponding involuntary eye movement, or nystagmus.
The recommendation at that point is to perform the appropriate treatment for BPPV crystals in the canal that is being tested, and then see if that improves their symptoms.
For both of the patients I saw today, they did not have any eye movement in the BPPV test position but they had uncomfortable symptoms during the BPPV test and they had a history of complaints consistent with BPPV.
So I assessed them as having “symptomatic BPPV.”
When we did the treatment for BPPV crystals in the specific canal that I was testing for, their symptoms resolved to zero.
If the symptoms in the BPPV test position are truly a “conditioned response,” then the symptoms will not improve so quickly with the treatment for BPPV crystals in the canal being tested.
Symptoms caused by a conditioned response will only improve over a matter of weeks with repeated exposure to the testing position through exercises that desensitize the brain to its conditioned response.
It is very important for the patients with vertigo to have the BPPV crystals treated before they try to push themselves through any aggravating movements.
Identifying and treating “symptomatic BPPV” is absolutely critical to optimal outcomes because head movements while BPPV crystals are still loose only cause agony for the patient, but head movement after BPPV crystals have been treated or ruled out completely is therapeutic in order to eliminate any remaining motion sensitivity or “conditioned response.”
This blog is provided for informational purposes only. The content and any comments by Dr. Kim Bell, DPT are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that Dr. Bell might see and do not describe the circumstances of a specific individual.
I have times when I have BPPV without nystagmus and there are times when I have full blown BPPV with nystagmus. I know the difference. It makes life very difficult to have either.
Hi Paulette, I agree that all types of BPPV makes life very difficult. I hope you are able to find a skilled provider in your area to help you. Best wishes.
Hello! Do people who do not have nystagmus still have the characteristic rotational vertigo? I am having an “inside my head” vertigo but it is positional–a first for me.
Traditionally, there is supposed to be a rotational component for BPPV diagnosis.
However, I have seen many patients who experience a quick wave, a few quick waves, or a prolonged feeling (usually for less than a minute) of nausea, blurred vision, spacey feeling, and/ or dizziness – without a rotational vertigo.
When I treat them for BPPV, those “waves” resolve.
I would say that is not a widely accepted approach to BPPV care, but I have found it worth a try!
If you need to find a vestibular physical therapist in your area, you can check out this blog for provider directories.
Kim Bell, DPT
Hi. I have experienced “head fullness/things moving in head”This first happened 12 years ago and it took about 3 months to resolve (an ENT said it was Meniere’s Disease but a neurologist said it was an inner ear disturbance that will resolve in about a month from when I saw him). My symptoms did resolve.
Since then I’ve had repeat episodes (with years in between). ENT’s say it’s not BPPV because no nystagmus but a neurologist at Columbia Presbyterian said it was BPPV.
My question to you is can I have BPPV without classic dizziness or nystagmus? If it is BPPV, then EPLY maneuvers should help. If not, it should resolve over time?
Thank you very much. I hope I gave clear enough information for you to understand.
You can have BPPV without nystagmus as I discuss in this article. For over ten years, I have been calling it “symptomatic BPPV.”
The researchers are now calling it “Type 2” BPPV. That type of posterior canal BPPV should still respond to Epleys, if they are done correctly.
You can also have BPPV in different canals that may not improve with Epley maneuvers. There are different maneuvers for each canal, so a thorough BPPV exam is needed.
The most important thing is to find a vestibular specialty health care provider and get a good vestibular exam.
You can use this article to search for someone in your area.
I hope you feel better soon!
I don’t have nystagmus and keep getting told they don’t think it’s bppv but I have all symptoms besides that of bppv I obviously have symptomatic bppv they’ve done maneuvers on me twice the first time it sent me into a two week episode of constant suffering of dizziness that didn’t stop. And this time my symptoms are even more terrible I’m on Valium and meclizine and still feeling terrible. How can my Dr treat my bppv crystals without any aggravating movement I don’t understand all head movement is aggravating. How can you treat and identify this bppv I obviously have lose crystals and they have put me in constant agony trying to treat me do I now have to wait weeks for this reaction to go away or do they have a way to treat this. I know you can’t tell me how to treat it but can they treat it. Can you talk Dr to Dr if a professional reaches out to you
Unfortunately, it is common to have the symptoms aggravated during or after treatment for vertigo.
That is normal, so many patients have to take medication in order to tolerate vertigo treatment. Even with medication, the treatment can be unpleasant and may cause a hangover effect.
I used to offer mentoring to other professionals, but I no longer offer that service.
You can learn about how to request a consultation with me here.
I am sorry for what you are going through and I hope you find relief soon!
Kim Bell, DPT
I cannot take meclizine or dramamine. It makes my dizzyness double. So I was given other meds at the hospital. I walked out of the $300 ER visit groggy and more dizzy. Going to an ENT in few days. Tried the epley and I got ear discharge. Still dizzy.
21 years ago, I had the same exact training at my very first Vestibular course. “No nystagmus: it’s not BPPV, so you can’t treat with maneuvers” I was told.
I turned more than a few people away those first few months when I was new/green to this treating this condition.
One Christmas eve, the emergency room sent a friend over. Her symptoms were exactly as expected with BPPV… but without nystagmus. I discussed the findings with her and told her “My recommendation is we go ahead and proceed with the maneuver and see how you respond.” (She couldn’t get any worse…) She agreed to proceed.
That maneuver was a game changer! Even though she “couldn’t have BPPV” she got better with the modified canalith repositioning maneuver.
She recovered and enjoyed her holiday and now I continue to see cases where there is no visible nystagmus – just symptomatic and exactly as expected with specific test positions.
I once saw that someone referred to those cases without a nystagmus as “BPPV” and those with nystagmus “BPPN”, but that certainly hasn’t gained much momentum.
Glad to find this old post… Thank you!
Therapist did not see nystagmus but instead went right into horrible head movements the Brandt daroff which made me so sick for the test of the day. I have old injuries to my neck and it was aggravated by the head movements! I spent 4 days bedridden because the bppv was worse, she would not treat me again until I got treatment for my neck, tried to explain to her that the epiley maneuvers always worked in the past. I still have significant vertigo spins when I move my head and my balance is terrible what went wrong?
I cannot speculate since I have not evaluated you in person, but if you re-read my article stating how I might treat patients who get dizzy with BPPV testing despite not seeing nystagmus, that might answer your question.
I hope you can use the general information I have shared to understand what might have happened to you.
If you need a physical therapist to treat your neck, I suggest finding someone on this directory if possible.
These home remedies may help as well.
Kim Bell, DPT
Must you always experience vertigo or spinning to have symptomatic BPPV?
Not necessarily, although classic BPPV is a spinning type of vertigo. Disequilibrium, and motion activated dizziness or nausea, can also indicate symptomatic BPPV.
If the symptoms improve with BPPV treatment, then in hindsight you may be able to conclude that it was likely symptomatic BPPV.
This article may help you learn about vestibular physical therapy.
I suggest that type of care as your next step.
This article has links to find someone in your area.
One and a half months ago, I felt vertigo for the first time while lying on bed and turning my head to my left bedside table to reach for something. Since then, turning my heard left/right/up/down also produced vertigo. Lying down with head movements were worse compared to standing/sitting up.
Two weeks later, my physical therapist did some head maneuvers for me. My vertigo symptoms improved but not diminished. The next day, I felt dizzy sensation on standing up (unsteady). It had been this way since then.
Two days ago, I went for my second physical therapy session. My therapist did another head maneuvers for me while asking me to wear a hugh eye magnifying equipment. She said I did not have nystagmus. However, I still felt internal spinning effect on closing my eyes and turning my head. I also felt dull headaches on head turning. Sleeping 8 hours a day seems like have not slept. I wonder if my vertigo is a central virtigo instead of a BPVP.
I am sorry to hear what you are going through!
As you suggested, there are many possible causes for the motion-activated symptoms you describe.
This blog has some home remedies that may help.
This article discusses strategies to manage dizziness with standing.
This directory may help you find an orthopedic manual physical therapist who can treat your neck and headaches. That may help.
I definitely suggest that you follow through with your vestibular physical therapy as well. Sometimes patients still benefit from BPPV treatment, even in the absence of nystagmus as I discussed in this article.
I hope you feel better soon!
Kim Bell, DPT
Thank you for this article. I am currently having a recurrence of disequilibrium symptoms on head movement (1st episode exactly 1year ago which self-resolved after 6-7 weeks). The symptoms fit with BPPV but I also don’t have nystagmus. Moreover, when doing Dix-Halpike I actually feel the disequilibrium on rising rather than when lying down. I have never had any manoeuvre done. Do you think it might be worth trying a manoeuvre or could it potentially make things worse?
I suggest that you find someone who is willing to assess you to determine if you would benefit from maneuvers. I cannot speculate without evaluating you in person.
Also, if you have dizziness upon rising, this blog may be helpful.
Kim Bell, DPT
My spinning is so severe I feel like I’m going to pass out which makes the exercises almost impossible. Is there any other way to approach this?
If the exercises are helping, then the reaction should gradually lessen over time.
If you feel you are not making progress, then you can use this article to search for another vestibular provider to get a second opinion.
This article also has home remedies that may help.
This article and this article discuss barriers to vestibular recovery that may be affecting your recovery.
In this article, I discuss what to do when vertigo exercises do not help.
I hope that information is useful to you!
Kim Bell, DPT
I am so glad to read this, going through RN and APRN school it is taught that nystagmus must be present with BPPV, but I myself have this (incidentally also dx’d by a Dr. Bell!) and have never had nystagmus.
Thank you for this. Does this sound like symptomatic BPPV – Every time I lean forward to pick something off the floor, reach into the dryer or sleep on my left side, I get left-sided dizziness – like a head whirring but only on the left side. It stops after about 20 minutes but will go on for longer if I do a number of these actions is succession. It’s generally worse in the morning but it depends on the amount and type of activity I do during the day.
Epley did not reproduce any symptoms but I’m definitely more off balance after Epley.
I’ve been through all of the testing and have no nystagmus. One Dr. said it’s migraines, the other said BPPV but both conceded they’re not sure and I just may have to live with it. I’m trying to decide whether I should keep trying Epley or give up and any feedback would be appreciated – it’s quite frustrating.
Motion activated dizziness can be from
BPPV, but there are other possible causes as well.
This article may help your learning about why the Epley may not help.
You can use this article to search a vestibular provider in your area.
I always suggest working with a trained professional who is experienced with particle repositioning maneuvers for BPPV.