Help MORE people with dizziness by screening for & treating the most common cause!

Sep 12, 2022

Dizziness is unbelievably common. We have all experienced some form of dizziness in our life and most of us know people who experience or suffer from dizziness. As a symptom, dizziness was once a great frustration in medicine – difficult to diagnose and assessment was a little ad-hoc. Thankfully, things have changed dramatically. Dizziness is no longer such a mystery, because we now have strong evidence for very effective ways of assessing and managing dizziness successfully for most people. Much of our success with dizziness is because the common cause of dizziness can be treated with some of the most effective and specific interventions that exist in the field of rehabilitation! And yes, we are not talking about a medication!

So, what is the most common cause of dizziness?

The answer is……

 Benign Paroxysmal Positional Vertigo (BPPV),

or sometimes just called ‘Benign Positional Vertigo’. It is thought that BPPV is caused by small calcium carbonate crystals called otoconia moving within in your inner ear. These crystals migrate away from their original location, on the walls of the otolith organs where they play an important role sensing linear acceleration of the head. In those with BPPV, the crystals fall off the walls and drift into one or more of the semicircular canals, where they don’t belong. This changes the sense of angular accelerations of the head, by altering the movement of the cupula, a small onion shaped hair cell located in each of the three semicircular canals (in each inner ear). The inconsistent movement of the cupula then creates a sense of dizziness which can range from mild to severe vertigo. The severity of the vertigo likely depends on how many crystals are moving around the semicircular canal, which canal or canals they are in (yes there can be in more than one!), how they interact or stick to the cupula. It also depends on how sensitised the whole system has become which includes how your brain perceives and interprets motion.

Why do the crystals fall off to begin with? This is an ongoing research question, but we know that previous inner ear infections, other vestibular conditions, migraine, head trauma such as concussion, medications, vitamin D and older age all play some role. For older people, the debris floating around the inner that leads to vertigo may also be made up of other additional degenerative tissues and products, not just otoconia from the otolith organs (1).

BPPV is therefore a mechanical problem where the debris is moving, creating inconsistent and unpredictable sensations of angular head movement and changes in position. Therefore, it is a form of positional vertigo. These sensations are often triggered by movement of the head and can lead to more angular or spinning dizziness sensations (but not always). The debris can behave a bit like sediment, like what you see in a red wine or a nice glass of pale ale beer. Sediment can move with gravity. Sometimes it sticks to the side and doesn’t move, sometimes is does! The bigger chunks tend to move faster, while small pieces tend drift more slowly. The hair cell can also change over time in terms of structure and sensitivity. This inconsistent behaviour is why the perception of dizziness varies in any individual and why symptoms and signs can be misleading. In our course

‘Positional vertigo - a comprehensive guide to treatment (Online)’

we explain these variables and provide you with ways to interpret findings and improve your diagnosis. A great many people will not complain of dizziness with changes in head position and the sensation is not always described as ‘spinning’ – hence our subjective examination has its limitations. Objective tests can often provide more clear information, and due to the movement of the debris with gravity – we have ways to move them back where they came from. Depending on which canal, how stuck or ‘stubborn’ the crystals are and which ear, we have dozens of specific repositioning manoeuvres to select from! Every day we treat people successfully with these manoeuvres in our clinics and teach patients ways to try these safely at home. Recent research shows that more than half the people attending a falls risk clinic can have undiagnosed BPPV! (2) Our comprehensive online course covers all the important treatment options.

So, the good news is that BPPV is very treatable, without drugs! Challenges remain however because BPPV is very common, it will very often reoccur, and it often coexists with other vestibular conditions. This includes other forms of positional vertigo which can be confused with BPPV. This is where specialist vestibular care plays an important role, and this is an important part of our work here in our Advanced Neuro Rehab clinics.

However, because BPPV is so common, we believe that more health professionals should know how to assess, treat the basics, and provide more informative referrals to specialist care if needed. To improve quality of life for more people, we belief that ALL GPs and Physiotherapists in particular, should gain a level of competence and confidence in these areas. Advanced Neuro Education provides some easy online courses to help you gain knowledge and skills that you can implement straight away.

Assessing the Dizzy Patient in General Practice, in addition to

Positional vertigo - a comprehensive guide to treatment.

We have been teaching these courses face to face for over 15 years and with our decades of clinical experience, we can help you learn the most important clinical skills online with best available evidence. These courses are specifically designed for ALL clinicians who would appreciate cost- effective and efficient learning. All our courses are supported by live and recorded online Q&A sessions to ensure we cover all your tricky questions. We are keen to build a growing community of practice, so I’m sure you will find this form of education invaluable.

As we say – ‘Changing practice, changing lives.’

Dr James McLoughlin

Lead Educator, Advanced Neuro Education


  1. Koç A. Benign Paroxysmal Positional Vertigo: Is It Really an Otolith Disease? J Int Adv Otol. 2022 Jan;18(1):62–70.

      2. Hawke LJ, Barr CJ, McLoughlin JV. The frequency and impact of undiagnosed benign paroxysmal positional vertigo in outpatients with high falls risk. Age Ageing [Internet]. 2021 Jun 11; Available from:

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