BPPV Recurrence: What Increases the Risk and What Does It Mean for Patients?

BPPV Recurrence: What Increases the Risk and What Does It Mean for Patients?

BPPV (benign paroxysmal positional vertigo) is one of the most common causes of vertigo. It can often be treated very effectively with the appropriate canalith repositioning manoeuvre, such as the Epley manoeuvre.

However, one of the frustrating things about BPPV is that it can come back.

If you have experienced BPPV more than once, you may understandably wonder why it keeps happening. Is there something you are doing wrong? Has the treatment failed? Should you be having more tests?

The answer is more reassuring than you might think.

Recurrence does not necessarily mean that treatment has failed. BPPV can recur even after successful treatment, and research has identified a number of factors that appear to be associated with a higher likelihood of recurrence.

A systematic review and meta-analysis by Li and colleagues examined 60 studies and identified 13 factors associated with recurrent BPPV. These included age, migraine, head trauma, diabetes, hypertension, high cholesterol, cervical spondylosis, reduced bone density, otitis media, prolonged computer use, sex and abnormalities on vestibular evoked myogenic potential (VEMP) testing. �

Sage Journals

So what does this mean in practice?

What is BPPV?

BPPV occurs when tiny calcium-carbonate crystals, known as otoconia, become displaced from their normal position within the inner ear and enter one of the semicircular canals.

When you move your head, these displaced particles can stimulate the balance sensors inappropriately, producing a brief sensation of spinning or vertigo.

Typical symptoms include vertigo when:

turning over in bed

lying down or sitting up

looking upwards

bending forwards

getting in or out of bed.

The vertigo associated with BPPV is usually brief, although it can be accompanied by nausea, imbalance or a feeling of unsteadiness afterwards.

A careful assessment can usually identify the affected canal and side. Vestibular physiotherapy can then be used to perform the appropriate repositioning manoeuvre and, where appropriate, provide exercises to help with any remaining dizziness or balance problems.

How common is BPPV recurrence?

Recurrence of BPPV is not unusual.

The research is difficult to reduce to one simple percentage because recurrence varies considerably between studies, depending on factors such as the population studied, follow-up period and definition of recurrence.

The important message for patients is therefore not that BPPV will return, but that having another episode does not necessarily indicate that the original treatment was unsuccessful.

This is an important distinction in vestibular rehabilitation.

If your BPPV returns months or years after successful treatment, this may represent a new episode rather than persistent BPPV that was never properly treated.

13 factors associated with recurrent BPPV

The systematic review by Li et al. identified 13 factors associated with BPPV recurrence. �

Sage Journals

The strongest associations in the review involved abnormalities in oVEMP and cVEMP testing.

VEMPs are specialised tests used to assess aspects of otolith function within the vestibular system.

Research has suggested that abnormalities, particularly involving the utricle, may be associated with recurrent BPPV. For example, one study found abnormal oVEMP responses were more common in patients with recurrent BPPV than in those whose BPPV did not recur. �

PubMed Central (PMC)

However, this does not mean that everyone with BPPV needs VEMP testing.

For most people with straightforward BPPV, diagnosis is primarily clinical, based on the history, positional testing and characteristic eye movements. Additional vestibular testing is generally considered when the presentation is atypical, recurrent or when another vestibular problem is suspected.

Diabetes was associated with recurrent BPPV in the meta-analysis.

The pooled analysis reported an odds ratio of approximately 2.87, meaning that the studies collectively found an association between diabetes and increased odds of recurrence. �

Sage Journals

This does not mean that someone with diabetes is destined to develop recurrent BPPV. An odds ratio describes an association within the research population; it cannot be used to predict an individual’s personal probability of recurrence.

Long-term computer use was also identified as an associated factor.

This is an interesting finding, but it is important not to interpret it as meaning that using a computer causes BPPV.

There may be other factors involved, including posture, reduced movement or characteristics of the populations studied. The evidence identifies an association rather than establishing a direct cause-and-effect relationship.

Abnormal cVEMP findings were also associated with recurrence.

cVEMP and oVEMP provide information about different parts of the otolith system. Abnormal VEMP results may therefore provide additional information in selected patients with recurrent or complicated vestibular presentations.

Again, VEMP testing is a specialist investigation rather than a routine requirement for every patient with BPPV.

Hypertension was associated with recurrent BPPV in the meta-analysis.

The pooled odds ratio was approximately 2.38. �

Sage Journals

For physiotherapists, this is a useful reminder that a vestibular assessment should not necessarily be viewed in isolation from the patient’s wider health.

Hyperlipidaemia was also associated with recurrence, with a pooled odds ratio of approximately 2.35. �

Sage Journals

As with the other risk factors, this represents an association found across the studies rather than proof that high cholesterol directly causes BPPV.

A history of otitis media was another factor associated with recurrent BPPV.

This is potentially relevant when taking a detailed history from someone presenting with repeated episodes of positional vertigo.

A history of migraine was associated with recurrent BPPV.

This is particularly interesting clinically because migraine itself can be associated with dizziness and vestibular symptoms.

For a patient who reports repeated episodes of dizziness, it is therefore important to distinguish true positional vertigo caused by BPPV from other causes of dizziness, including vestibular migraine.

The two conditions can also coexist.

Previous head trauma was associated with increased odds of recurrent BPPV.

This makes clinical sense because trauma can affect the vestibular system and may contribute to displacement of otoconia.

A history of head injury is therefore worth considering when taking a vestibular history, particularly when BPPV develops following an accident, fall or blow to the head.

Increasing age was associated with BPPV recurrence, with the review identifying age 65 years and over as a risk factor.

Age-related changes within the vestibular system may be relevant, alongside changes in bone health and other medical conditions.

This is also one reason why recurrent dizziness in an older person deserves careful assessment rather than automatically being attributed to BPPV.

Reduced bone density, including osteopenia and osteoporosis, was associated with recurrent BPPV.

This is an interesting area because the inner ear’s otoconia are calcium carbonate structures, and researchers have investigated relationships between bone metabolism and BPPV.

Importantly, the review did not find that vitamin D levels alone were predictive of recurrence. �

Sage Journals

Cervical spondylosis was also associated with recurrence.

This does not mean that neck arthritis causes BPPV. However, neck stiffness can sometimes make positional assessment and treatment more difficult.

For vestibular physiotherapists, this is particularly relevant when considering how safely and comfortably a patient can move into the required positions for diagnostic testing or a repositioning manoeuvre.

The review also found an association between female sex and recurrent BPPV.

This is a statistical finding from the populations included in the review rather than an explanation for why an individual patient develops recurrent BPPV.

What does this mean if you have BPPV?

Perhaps the most important message is:

Having one or more of these risk factors does not mean that your BPPV will definitely return.

These factors were identified because they were associated with recurrence across the studies included in the systematic review. They are not a checklist that can predict exactly what will happen to an individual patient.

In fact, many people with BPPV will have none of these factors and may still experience another episode.

Conversely, having diabetes, migraine, osteoporosis or one of the other factors does not mean that you will necessarily develop recurrent BPPV.

The findings are therefore better viewed as risk markers rather than predictions.

What does this mean for vestibular physiotherapy?

There are several useful implications for physiotherapists working in vestibular rehabilitation.

A patient’s medical history should not distract from the fundamental clinical task.

If the presentation is consistent with BPPV, appropriate positional assessment should be undertaken and the affected canal identified where possible.

The appropriate canalith repositioning manoeuvre can then be performed.

Vestibular physiotherapy is not simply about giving balance exercises. For BPPV, accurate diagnosis and appropriate repositioning are central to treatment.

If someone returns several months later saying:

“My BPPV has come back.”

that is a reason to reassess, rather than simply assuming that the previous diagnosis and affected canal were the same.

The new episode may involve a different canal or side, or the symptoms may have a different cause altogether.

This is particularly important when the symptoms do not fit the typical pattern of BPPV.

A patient with recurrent BPPV may have other factors worth discussing with their GP or other healthcare professional.

For example, appropriate patients may benefit from medical review of:

diabetes

blood pressure

cholesterol

bone health

migraine

previous head trauma

recurrent ear problems.

The role of the physiotherapist is not to diagnose or manage all of these conditions, but recognising relevant history can help ensure appropriate onward management.

The findings relating to VEMP testing are interesting, particularly for clinicians working in specialist vestibular rehabilitation.

However, an abnormal oVEMP or cVEMP is not required to diagnose ordinary BPPV.

Specialist vestibular investigations should be considered according to the clinical presentation and where the results are likely to add useful information.

What about vestibular rehabilitation after BPPV treatment?

For some patients, treating the positional vertigo is only part of the rehabilitation process.

After successful repositioning, some people continue to experience:

mild dizziness

imbalance

visual sensitivity

motion sensitivity

uncertainty when walking

difficulty moving the head quickly.

In these situations, vestibular rehabilitation physiotherapy may be useful.

Vestibular rehabilitation can include individually selected exercises aimed at improving gaze stability, balance, habituation and confidence with movement.

There is also some research suggesting that rehabilitation may have a role in people with BPPV and associated otolith dysfunction. One small study found lower recurrence following repositioning combined with a rehabilitation programme compared with repositioning alone in patients with documented otolith dysfunction. However, this was a small study of 45 people, so the findings should not be generalised to everyone with BPPV. �

PubMed Central (PMC)

Does recurrent BPPV mean the treatment didn’t work?

Not necessarily.

This is one of the most important things I would want patients to understand.

A repositioning manoeuvre can successfully treat an episode of BPPV, while the condition can still recur at another point in the future.

Think of it in a similar way to other episodic conditions: successfully treating one episode does not necessarily guarantee that another episode can never occur.

The aim of vestibular physiotherapy is therefore not to promise that BPPV can never return. It is to identify the problem accurately, treat it appropriately and help you understand what to do if symptoms return.

When should you seek assessment for dizziness?

If you have previously had BPPV and suddenly develop brief spinning sensations when turning in bed, lying down, sitting up or moving your head, BPPV is one possible explanation.

However, not every episode of dizziness is BPPV.

Seek appropriate medical assessment if your symptoms are new, unusual, persistent or associated with other concerning symptoms.

A physiotherapist with expertise in vestibular rehabilitation can assess whether your symptoms are consistent with BPPV and whether further assessment or referral is appropriate.

The bottom line

BPPV is very treatable, but recurrence is possible.

Research has identified a number of factors associated with recurrent BPPV, including migraine, head trauma, diabetes, hypertension, hyperlipidaemia, cervical spondylosis, reduced bone density, otitis media, prolonged computer use, age, sex and abnormalities in VEMP testing. �

Sage Journals

These factors should not be interpreted as a prediction that an individual patient will experience recurrent BPPV.

For patients, the key message is simple: if your BPPV comes back, it does not necessarily mean that your previous treatment failed.

For physiotherapists, recurrent BPPV is an opportunity to reassess the diagnosis, consider the patient’s wider health and identify whether vestibular rehabilitation or further investigation may be appropriate.

And perhaps most importantly, patients should know what to do if their symptoms return.