Vertigo Myth: BPPV = Dix-Hallpike test, the patient gets dizzy, and you see nystagmus

[@michaelrichards39]

most informative video on vertigo I've seen. thank you

[@zachbrown2514]

Thank you so much for these videos! As a chiropractic student we learnt about BPPV but never to this level of differentiation and clinical examples. This has helped my vertigo exam skills immensely!

[@southern-samurai]

Your videos have been gold for me as an Australian Paramedic. So many patients present with vertigo or “dizziness” with vascular risk factors, and our guidelines are just not thorough enough in differentiating central vs peripheral causes.

[@prakashnachinolker610]

Hi Dr Peter you are excellent teacher.Please decrease ur speed while speaking it will help us in better grasping the informations of vertigo..

[@PeterJohns]

Some people like faster talking, some like it slower. You can always adjust the speed of the videos also.

[@conveyorbeltz1]

I had always planned on naming my future dog Sarcomere, however, you have inspired me to name him Otolith. Love your videos...and Epley!

[@PeterJohns]

Gufoni, Semont, there are a few good ones left!

[@nicoloberdin2970]

Very clear and thorough, thank you!

[@ericandrius]

Love when there is a new vídeo. Please post more!!!

[@tylersmith5503]

You rock for these videos Dr. Johns!

[@lauragwillim1055]

Great info! I’m a PT

[@nikkihaggerty9094]

Epley! Like the Epley maneuver! Amazing.

[@PeterJohns]

Yes, I wasn't sure about naming him that, but it seemed to be a good name for yelling in a dog park. And I have compartmentalized the maneuver and the dog. Kind of like if you read about Buffalo NY, or order Buffalo wings, you don't automatically think of big lumbering bison.

[@whonix4317]

Great video. I knew some of it after 30 years of practice but not all. Rather than label the chronic cases as Vestibular Migraine I’m glad I’ll be able to r/o the 3 BPPVs 1st.

[@cesimpsonv]

Your content is aweosome! Thank you so much for doing this, it's been very helpful. Greetings from Chile! 🇨🇱

[@smca7271]

Interesting vid...I had tumors on cerrebellum and if I do the hallpike maneuver the room spins for 20 secs,but doing the elpy maneuver does not help...its a complicated system..VOR helps heaps.

[@PeterJohns]

Do you get nystagmus? And if so, what type?

[@smca7271]

@PeterJohns I use to ...left to right I think....but after 3yrs I do not have nystagmus,lots of VOR has fixed this.

[@NinjaSheepa]

Hey, love your stuff Video suggestion: I would love it if you could do a video on how you approach those unsatisfying patients constant or vague vertigo with no pathological exam findings that almost always seem to get an MRI or an ENT consult that will always results in nothing.

[@PeterJohns]

Thanks for your interest and suggestion. I'm not sure I'll get to making a video about this. I have a list of at least a dozen topics for videos that I want to make before I would tackle this one. A short answer would be that those patients who would screen negative for central features as per my algorithm in my paper www.cmaj.ca/content/192/8/E182 and have no nystagmus, or difficulty with gait or other concerning features in their history or presentation are likely safe for discharge and follow up with their family MD or dizzy interested physician. The diagnosis that is most commonly missed, and is almost as common as BPPV, is vestibular migraine. See my video about this. kzbin.info/www/bejne/joGsqoufq5WIgck If you see undifferentiated dizzy patients, you really should be aware of how to make this diagnosis. It will start popping up remarkably frequently. It is 10 times more common than Meniere's disease. The other diagnosis that is common in dizzy specialists clinics is PPPD. I personally haven't seen many cases, and I'd be hesitate to make a video about a diagnosis I rarely see. But here is a rather long but excellent article about it. pn.bmj.com/content/18/1/5. Hope this is helpful.

[@NinjaSheepa]

@@PeterJohns Thanks a lot!

[@eyalokin]

Amazing content! Thank you so much!!

[@vitordallastarigo5785]

Hi Peter! So, if a patient has what seems to be BPPV and does not get better with two Epley maneuvers for posterior canal BPPV, a Gufoni maneuver and BBQ roll for horizontal canal BPPV and a deep head hanging maneuver for anteior canal BPPV, in which cases should I refer the patient to a vertigo specialist? Only in case of anterior canal BPPV? It looks clear to me that posterior canal BPPV does not have a central cause and anterior canal does but I didn’t understand if horizontal canal BPPV can too have a central cause. And is this an emergency situation or it can be solved through ambulatory care?

[@PeterJohns]

Geotropic positional nystagmus is pretty much never caused by anything but Geo HC BPPV. Apogeotropic positional nystagmus can rarely be caused by a small stroke. If the patient cannot be cured of their symptoms with positioning maneuver, or if any of the central features that I list in my Big 3 algorithm kzbin.info/www/bejne/g6jFon2sgqmipLc are present, then a urgent consult with a neurologist is warranted. All others could likely be referred to ambulatory care. This is my opinion, in any case.

[@TheKCMadrid]

Thank you Dr Peter for these well-informed and fruitful videos. Am wondering if there's an article/study explaining or supporting the use of a piece of paper for removing visual fixation? lastly, I'd like to hear from you about Vestibular neuritis vs acute labyrinthitis if you please, thank you in advance.

[@PeterJohns]

It's briefly mentioned in this paper- "Penlight-cover test: a new bedside method to unmask nystagmus" by David Newman-Toker. He references a textbook by David Zee which I don't have access to. Occlusive ophthalmoscopy is another technique to remove fixation. Regarding vestibular neuritis vs viral labyrinthitis, here is an answer I have given before. Certainly looking for new hearing loss in patients with vertigo will increase the sensitivity, and decrease the specificity of HINTS. What the incidence is of labyrinthitis vs an AICA stroke presenting with hearing loss, vertigo and abnormal HIT is not known. I would say this: If someone had a viral URI, developed ear pain and then tinnitus and/or hearing loss and vertigo, with no concerning features or risk factors for posterior circulation stroke, I'd probably call it viral labyrinthitis and send them home. If an older person or with stroke risk factors developed a sudden onset of vertigo and hearing loss at the same time, without URI or ear pain, and had an abnormal HIT, and a new hearing loss, I would work them up for AICA stroke. Every other patient in between these two scenarios is going to depend on your resources, your tolerance for risk, and local practices.

[@ashaosbon7308]

these incredible vidoes would be even more incredible if you spoke a tiny bit more slowly! my brain struggled to keep up with this complex subject

[@jlynno111]

hey... someone showed me something you might like. Go to the video... and look for the little wheel on the right at the bottom of the screen. You can find it immediately to the right of the CC button. When you click on the wheel it allows you to change the playback speed.... you might prefer playing at 0.75. Try it out!

[@alfredopampanga9356]

I get it In order to tackle BPPV it’s convenient to discuss posterior canal and horizontal canal as discrete entities. However , whatever the pathogenesis is exactly , it’s unlikely that it will fit our preferred schema. I’m willing to bet that mixed BPPV is common but tricky to diagnose.

[@PeterJohns]

I have seen multi-canal BPPV. The suggested approach is to try to clear the most symptomatic one first. It worked the one or two times I have seen this.

[@chrisgraves310]

Never had vertigo till 6 days ago. It came on quick and violent. Sweating, vomiting, nausea,vertigo. I can barely walk. Sent home from ER with BPPV diagnosis. Feels like I had a stroke.

[@robertcornelisse8664]

This happened to me 8 days ago. They sent me home saying i have a inner ear infection. How are you doing now?. I am still having problems with walking.

[@TroopsofDoom666]

@@robertcornelisse8664 me too this is the fourth times i had it....1st and 2nd was the horrible...3rd and fourth it Just mild symtomps...i did empley manuever....12 times... i knew its went away but i have to stay alert...i sleep with 2 pillows...not sleep on the affected side

[@robertcornelisse8664]

@@TroopsofDoom666 just saw your reply. I hope you doing better now. I still have vertigo, someone drove in the back of my car in June that mafe my vertigo come back.

[@TroopsofDoom666]

@@robertcornelisse8664 im ok sir.. i cut off salted and fat foods...reduce coffee...alcohol....i go walk in the jogging park for atleast 30 minutes per day....3 times a week....hope you doing well sir 😀✌

[@robertcornelisse8664]

@@TroopsofDoom666 I am happy you doing well. I have a lot of ups and downs. But hopefully it will get more stable in the future.

[@sman5877]

thanks so much 😊

[@onesky5570]

Hello doctor, question here: my mom had sudden vertigo with head movements, she got diagnosed with BPPV (not sure which kind) and did physiotherapy for a little bit, her dizziness has improved dramatically but she still complains of « residual » dizziness when getting out of bed, less intense than before treatment but it’s still there. A google search showed me a lot of people with BPPV suffer from residual dizziness post treatment, so can I rest knowing this is a normal thing for BPPV patients? keep in mind she doesn’t suffer from any other central symptom, only dizziness with head turns. Also what can one do about this residual dizziness post treatment? and thanks

[@PeterJohns]

Post maneuver dizziness often resolves on it's own. If not vestibular physiotherapy can be helpful.

[@harishchandergoel5159]

Nice 👍

[@MsJlaurealdrich]

What do you do if you have a patient who reports hours/days of continuous vertigo made worse with head movements but there is no nystagmus (even when using the white paper trick)? I tried DHP which was negative (though patient was really struggling to cooperate and kept moving forward so her head wasn't fully extended off the bed...) Thanks!

[@PeterJohns]

Did she have an objective acute change in her gait? Any history of migraines headaches?

[@MsJlaurealdrich]

@@PeterJohns Thanks so much for your quick reply! Her gait was fine - no ataxia, she could walk unaided without difficulty. She did have a mild headache during this visit. She had had headaches in the past but no dx of migraine. She had also felt dizzy before but could not link the two symptoms together (i.e. could not say at least half her dizzy spells previously were accompanied by headache)

[@PeterJohns]

@@MsJlaurealdrich a significant proportion of people with vestibular migraine never get a headache with a dizzy spell. Watch my video on vestibular migraine, and if you have any questions after that I’m happy to answer them.

[@MsJlaurealdrich]

@@PeterJohns Awesome! Thanks!

[@Nafi33]

Very informative videos, thanks a lot! I was wondering how we can differentiate between vestibular migraine (which I suppose we should classify as a central cause) and another central cause, let's say a posterior circulation stroke? Is it that in case of a stroke, nystagmus is present while in the case of vestibular migraine there is none? If yes, is there always nystagmus in the case of a stroke, and is nystagmus always absent in case of vestibular migraine? Greetings from the Netherlands.

[@PeterJohns]

Tricky. First episode(s) of VM could be confused with a PCS. But if the patient meets the definition of VM, kzbin.info/www/bejne/joGsqoufq5WIgck and the current episode seems similar to many previous episodes, then likely it's VM. Usually VM does not have spontaneous nystagmus if fixation is not removed. And certainly PCS can present with no nystagmus. But PCS likely will have some other central feature, or acute imbalance. Patients with dizziness, acute imbalance, but no nystagmus are at high risk for stroke. Hope this helps.

[@lizicadumitru9683]

What if someone has Vertigo but no typical nystagmus and none when the DHT is done?

[@PeterJohns]

If it's only on one side, with the typical latency, and duration of symptoms of posterior canal BPPV, then it could be subjective BPPV. I think it's quite rare, but I have seen it. Some think it's common. In any case, if you see what I just described it's worth trying to treat with the appropriate Epley maneuver.

[@PK-ez7bn]

As a vestibular PT who does not have much access to goggles, I see this clinically on occasion. It can be false negative testing, even with loaded DHT. I will repeat testing DHT and then move to sidelying test. But I agree that taking someone through mod epley works more often than not if their symptoms line up with BPPV.

[@PeterJohns]

@@PK-ez7bn The weird thing is when people say subjective BPPV is 25 % pubmed.ncbi.nlm.nih.gov/21998085/ or one study that claimed 60% of the patients diagnosed with BPPV has subjective BPPV! www.ncbi.nlm.nih.gov/pmc/articles/PMC8120855/ I really can't explain that. Not my experience whatsoever.

[@mdshett2]

Can you have BPPV without nystagmus?

[@PeterJohns]

Yes, there is a phenomena called "subjective BPPV". This is a somewhat controversial topic. Some think it's common, others rare. I have only seen it once. My view is this: If the patient has the typical story for BPPV, and during the DHT, one side is negative and the other has vertigo with the typical latency of posterior canal BPPV, and duration, but no nystagmus is seen, and if you perform the Epley maneuver and wait 15 minutes and repeat the DHT and no vertigo is produced, well then, that's probably subjective BPPV. Like I said I have only seen one case like that, in the background of dozens of posterior canal BPPV patients, so I think it's rare. Why other people report much higher percentages, I don't understand.

[@giselleruemke501]

Thank you Peter Johns. It's helpful to understand this better. But can't nystagmus be quite easy to miss in some patients? Apparently in room light, I will beat once or twice, then fix, as has been observed by two of the four vestibular therapists I've seen, with exception of one crazy bad day, when it was just nuts and super obvious in roomlight, no goggles. I worked with a therapist for some time who didn't think I had BPPV and was shocked when he goggled me to see that I did show nystagmus. I would say that to be sure, use the paper test to remove fixation, unless you have Frenzels. I had also heard through two therapists that there can be a connection between the capacity to visually fix or to override nystagmus that is correlated with Post Traumatic Vision Syndrome and Visual Vestibular Mismatch.. Have you seen this or read about it, or do you also feel this is true, Peter Johns? Thank you!

[@giselleruemke501]

@@PeterJohns Thank you Peter Johns. It's helpful to understand this better. But can't nystagmus be quite easy to miss in some patients, without goggles? Apparently in room light, I will beat once or twice, then fix, as has been observed by two of the four vestibular therapists I've seen (with the exception of one or two crazy bad days, when it was just nuts and super obvious in roomlight, no goggles). I worked with a therapist for some time who didn't think I had BPPV and was shocked when he goggled me to see that I did show nystagmus. I had also heard through two vestibular therapists that there can be a connection between the capacity to visually fix or to override nystagmus that is correlated with Post Traumatic Vision Syndrome and Visual Vestibular Mismatch.. it was explained to me that I did not show nystagmus in room light because my brain was over-relying on my vestibular system to orient me in space. Have you seen this or read about it, or do you also feel this is true, Peter Johns? I wonder if this could be why more folks don't show nystagmus as well.. if they have VVM or PTVS and are just walking around for years, like me, dealing with BPPV as well. Interested to hear your what you think. Thank you!

[@PeterJohns]

@@giselleruemke501 Sorry, I don't know about what you referred to. My focus is to teach medical professionals who know little about vertigo how to correctly diagnosis the common causes. Hope you feel better soon.

[@NN-rn1oz]

I'll be honest. I often consider BPPV a diagnosis of exclusion after ruling out central vertigo and other more dangerous/urgent Ddx... (shame).

[@PeterJohns]

Interesting. Honest question, how do you rule out a central vertigo in patients with the typical presentation of BPPV?

[@NN-rn1oz]

@@PeterJohns Here is my overly crude approach to ruling out a central cause: if there's dysphagia/dysphonia/dysmetria/dysdiadochokinesia/diplopia or any other focal deficit (esp. on cerebellar tests and gait abnormalities), I send the patient to CT. I always feel more comfortable ruling out a dangerous Ddx than ruling in a benign one... But I know I'm guilty of overtesting. I have to find the courage to learn the skill of identifying the different forms of nystagmus!

[@NN-rn1oz]

Also, if they have constant vertigo and a negative head impulse test, it points towards a central cause. And if my suspicion for central remains high despite a negative CT, this warrants a consult..

[@PeterJohns]

@@NN-rn1oz OK, so looking for central features, like the dangerous D's as you outlined, is at 2:58 of this video. I bet you haven't seen anything on CT head that would cause their dizziness on the ones that you ordered on those who screened negative for central features, had at typical story if BPPV,, and had a typical positive Dix-Hallpike test. Do the Epley, make them feel better and send them home with no labs, no IV, no imaging. With regard to constant vertigo AND nystagmus, a yes, normal head impulse test bilaterally is not consistent with vestibular neuritis and you should work them up for stroke. Also, as I stated at 2:30, BPPV patient not infrequently say they are dizzy at baseline. So if you do a HIT on patients with BPPV who have no nystagmus but say they are still dizzy. you will get a normal HIT, which will lead you to thinking it might be central. Instead, do a Dix-Hallpike test on these patients and if negative, a supine roll test. Gerlier (pubmed.ncbi.nlm.nih.gov/34245635/ You would have to download the study to see all this) recently did a study where she performed HINTS on patients with constant dizziness but didn't have spontaneous nystagmus as an inclusion criteria. And guess what the most common diagnosis was? BPPV! More common than either vestibular neuritis or posterior circulation stroke. And HINTS of course was often falsely central on theses patients. So don't do HINTS on patients with constant dizziness and nystagmus. CT head are very poor for anything but hemorrhage and tumors (both rare causes of isolated vertigo, whether spontaneous or positional).

[@NN-rn1oz]

@@PeterJohns Thank you so much for your help with this topic! Yes CT has poor sensitivity esp. in the first few hours from onset, which is why a negative result should never override clinical suspicion. I will read the studies you suggested. Thanks again!

[@aragonthebrave]

Sir ....can a spontaneous or gaze evoked nystagmus NOT be due to a central cause or in other words ,have you seen people with bppv present with gaze evoked nystagmus??

[@PeterJohns]

Actually, the most common cause of spontaneous and/or gaze evoked nystagmus is vestibular neuritis, which is a peripheral cause. In terms of seeing spontaneous or gaze evoked nystagmus, posterior canal BPPV will not produce this. I have seen a few cases of horizontal canal BPPV causing spontaneous nystagmus, which is termed "pseudo-spontaneous nystagmus". That is because you can position the head so that it stops. You can't do that with real spontaneous nystagmus. I made a video all about this already! The answer to your question starts at 0:344. kzbin.info/www/bejne/m6TGf2ZvmK55gcU

[@aragonthebrave]

@@PeterJohns thanks for the reply sir ....helpful indeed...

[@victorliu3012]

@@PeterJohns Hi Peter. I just wanted to clarify this. So if I am seeing a patient with vertigo, and I ask them sit still and look to the right and left, and I see a unidirectional horizontal nystagmus (I assume this is what is meant by 'gaze-evoked' nystagmus), then this is NOT BPPV (of any of the canals) and I should NOT perform a Dix-Hallpike. Would this be correct?

[@PeterJohns]

@@victorliu3012 It definitely is not posterior canal BPPV, so Dix-Hallpike testing is not indicated. However, (and this is an advanced topic) you can get pseudo-spontaneous nystagmus in horizontal canal BPPV, so performing a supine roll test would be a good idea. See this video at this time stamp. kzbin.info/www/bejne/m6TGf2ZvmK55gcU Assuming that the supine roll test does not demonstrate horizontal canal BPPV, then a patient with ongoing vertigo and nystagmus should have the HINTS exam performed them, to see if they are having vestibular neuritis (more likely) vs a subtle cerebellar stroke which is presenting like vestibular neuritis. If they have neuro signs or symptoms not consistent with vestibular neuritis, then work them up as a stroke.

[@victorliu3012]

@@PeterJohns Thanks for the reply Peter! I shall apply this whilst in the ED.

[@splitkostanjeuma]

I just had a patient that said he yesterday had 2 mayor episodes of vertigo. Had some history of vertigo but says never this severe. He said it started when he lifted his head up, lasted for 15seconds and then stopped. 2nd episode was the same. Had some nausea, didn't vomit. When he came in today he was walking normally, said he didn't have vertigo at the moment, but had a headache, slightly pulsating but both sides. No spontaneous or gaze evoked nystagmus. The DHT was negative on both sides, as was the supine roll test. Can vestibular migraine present with such short episodes of vertigo and was it in this case the most likely diagnosis?

[@PeterJohns]

There are a couple of possibilities. Spontaneously resolved BPPV would be one. See my video on vestibular migraine to see if he had enough to meet diagnostic criteria. Having not seen him myself, hard to say more than that.

[@splitkostanjeuma]

@@PeterJohns Any ideas on how often BPPV resolves spontaneously?

[@PeterJohns]

@@splitkostanjeuma For horizontal canal BPPV, it is probably very common. For posterior canal, takes longer, generally.

[@splitkostanjeuma]

@@PeterJohns Thanks.

[@tomheffernan1572]

You put Epley to sleep

[@PeterJohns]

Only because he's heard it all before!