Positional Vertigo

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Positional Vertigo

In Brief

It occurs when tiny calcium crystals in the inner ear come loose and slip into the balance canals; it is often called “ear crystals”.
Typical is a brief, intense spin – usually under a minute – when lying down, turning in bed, or looking up or down; nausea may come with it.
Sudden head movements, head injury, age-related inner-ear changes and long periods of bed rest are the main causes.
It is diagnosed with special positioning tests during the examination and treated with manoeuvres that move the crystals back into place.

⚠️ Emergency: If dizziness comes with slurred speech, a drooping face, weakness in an arm or leg, double vision or being unable to walk, do not wait – call 112 (emergency).

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What Is Positional Vertigo and How Common Is It?

Positional vertigo is one of the two most common causes of dizziness in the general population (the other is vestibular migraine, also called migrainous vertigo). It is the most common cause of dizziness in all age groups and is characterized by brief, severe episodes of dizziness triggered by movement.

Balance begins in the ear!

The ear is the most important component of our balance system. The balance part of the ear consists of three semicircular canals and two small chambers into which they open, the utricle and the saccule, together called the vestibule. All of these canals and chambers are connected to one another. Unlike the hearing system, this system is responsible for sending information about head movements to the brain, our balance center. Every head movement creates fluid movement in the semicircular canals and in the chambers of the vestibule. This movement stimulates the main sensory cells of balance, and the signal travels to the brain through the balance nerve (vestibular nerve). The brain processes this signal to sense the position of the head in space and, accordingly, to maintain balance.

Within the chambers of the vestibule, calcium carbonate crystals called otoliths sit on the sensory cells responsible for balance. Their main purpose is to let us sense forward-backward and up-down movements through the effect of gravity. Under normal conditions, these calcium carbonate crystals are found only in these chambers (the utricle and saccule) and not in the semicircular canals.

The semicircular canals detect rotational movements of the head, such as looking left and right or up and down. The systems on the two sides work in opposite directions: when we turn our head to the right, the signal from the right side increases while the signal from the left side decreases. This creates the sense of turning to the right in the brain.

Signals from this system are also sent to the eyes. The muscles around the eyes contract in response to the movement, so when we turn our head to the right, our eyes reflexively move to the left. In medicine this is called the vestibulo-ocular reflex.

What Does Positional Vertigo Mean?

As mentioned in the previous section, the calcium carbonate crystals are located in the chambers of the vestibule. Because of their weight, they help detect gravity-related up-down and forward-backward movements. These crystals are not normally found in the semicircular canals.

If, for any reason, calcium carbonate crystals enter the semicircular canals, they cause dizziness during head movements. The main reason is that the weight of the crystals disrupts the normally synchronized activity of the right and left sides. On the side with the crystals, the fluid behaves as if it were heavier, so during a head movement the fluid on the right and left sides moves out of step. The result is confusion in the brain. The mismatched signals sent to the eyes cause jerking eye movements, which make the surroundings appear to move. This is an illusion of movement: a sensation of motion that is not real and comes entirely from this mismatch. In medicine these jerking eye movements are called nystagmus.

The dizziness lasts less than a minute but is very intense, and may feel like an earthquake to the person affected. Because the balance system is connected to the autonomic nervous system, many other symptoms can appear in this short time, most notably nausea, vomiting, palpitations, sweating, a fast heart rate (tachycardia) and a fear of dying.

Dizziness is triggered by movement in the direction of the affected semicircular canal, which is why the condition is called positional vertigo: the head must move in the plane of the affected canal for the dizziness to start. For this reason, patients try to avoid the triggering positions. Because every triggering position can restart the dizziness, people slow down their movements, and this restriction of head movement can in turn lead to neck pain and anticipatory anxiety.

What Causes Positional Vertigo?

The reasons why calcium carbonate crystals slip into the semicircular canals differ between age groups. In younger people, the most common causes are sudden head movements (whiplash injury), putting the head in an unusual position (pilates, yoga, hanging curtains, looking up for a long time) and blunt head injuries. In middle-aged and older people, the usual causes are age-related degeneration of the inner ear and illnesses that require long periods of bed rest.

Because of gravity, detached calcium carbonate crystals most often (about 80%) enter the lower (posterior) semicircular canal. Crystals in this canal cause brief, intense dizziness especially when looking up or down, lying down on the back, getting out of bed, going down stairs or bending to tie shoelaces.

The side (lateral) semicircular canal is affected less often (15–20%). When this canal is affected, dizziness occurs when looking to the left or right and when turning from side to side in bed.

Diagnosis of Positional Vertigo

Positional vertigo is usually easy to diagnose. The affected canal or canals can be identified at the bedside, with the naked eye or with VNG (video goggles). Identifying the correct canal is also essential for treatment, because a repositioning maneuver performed for the wrong canal can move the crystals into another canal (known in medicine as canal conversion). Repositioning maneuvers performed after diagnosis are very successful. When positional vertigo is treated early, the chance of recurrence is about 10–15% in the first year and about 30–40% within the first 5 years.

Treatment of Positional Vertigo

Positional vertigo is essentially a mechanical problem. Calcium carbonate crystals that have detached from the vestibule (the chambers) enter the semicircular canals and cause brief, intense dizziness with head movement. Because the cause is mechanical, the treatment is mechanical as well.

Various maneuvers are used to move the calcium carbonate crystals back into the vestibule and treat the condition. The maneuver chosen depends on which semicircular canal is affected (for example, the Epley, Semont or Gufoni maneuver).

After the maneuvers, the symptoms of the condition resolve. The condition recurs in about 10% of patients in the first year and in about 30–40% within the first 5 years.

Even after the maneuvers have returned the calcium crystals to the vestibule, some patients continue to have a perceptual balance disturbance that is not as severe as the vertigo but partly limits daily life (Persistent Postural-Perceptual Dizziness, PPPD). This varies from person to person and may last from days to months. While positional vertigo itself is treated with maneuvers, medication may be used to manage this residual dizziness.

If repositioning maneuvers are not performed in time, or residual dizziness is not adequately treated, many psychological problems can develop in the long term, ranging from anticipatory anxiety to depression. Positional vertigo begins as a physical condition, but delayed treatment can turn it into a psychological one. Early diagnosis and treatment are therefore very important.