BPPV Is Cured in One Clinic Visit. Why Are Indians Still Taking Pills for Months?

Inside your inner ear, three fluid-filled canals track head movement. Sitting next to them is a small chamber called the utricle, which contains tiny calcium carbonate crystals called otoconia. When one of these crystals breaks loose and drifts into a semicircular canal, it sends the brain a false signal every time the head moves in a particular direction. The brain interprets this as spinning. That is the entirety of BPPV: a loose crystal in the wrong place.

The vertigo it produces is brief, usually lasting under a minute, and is triggered by specific movements, lying down, rolling over in bed, tilting the head back to look up. The briefness is actually diagnostic. A vertigo episode that lasts hours points toward something else entirely.

Diagnosing BPPV does not require an MRI, a CT scan, or a blood panel. A trained clinician, a neurologist, ENT specialist, or physiotherapist who works with vestibular conditions, performs the Dix-Hallpike manoeuvre. The patient sits on an examination table, the clinician turns the patient's head 45 degrees to one side and lowers them quickly to a lying position with the head hanging slightly off the edge. If the affected canal is posterior, characteristic nystagmus, an involuntary rhythmic eye movement, appears within seconds and fades within a minute. That nystagmus is the diagnosis.

The test identifies which ear is affected and, in most cases, which canal. That information determines the repositioning manoeuvre used to treat it.

The Epley manoeuvre, developed by otolaryngologist John Epley in 1980, guides the displaced crystal back out of the semicircular canal and into the utricle, where it causes no symptoms. The clinician moves the patient's head through a sequence of four positions, pausing at each for roughly 30 seconds to let gravity carry the crystal along. The whole procedure takes under 15 minutes.

A 2014 Cochrane systematic review of 11 randomised controlled trials found the Epley manoeuvre significantly more effective than a sham or no treatment for posterior canal BPPV, with resolution rates in single-session studies consistently above 70 percent and rising toward 90 percent after a repeat session. For the most common form of BPPV, posterior canal, this is as close to a mechanical cure as medicine gets.

Some patients feel briefly nauseated during the procedure. Some need a second session a week later. A small number have horizontal canal BPPV, which responds to a different manoeuvre called the Barbecue roll. None of these variations require medication to resolve.

Betahistine and cinnarizine are vestibular suppressants. They reduce the intensity of the vertigo signal but do not move the crystal. Taking them for BPPV is the clinical equivalent of turning down the volume on a fire alarm rather than finding the fire.

The Bárány Society, the international body that sets standards for vestibular disorders, does not recommend vestibular suppressants as primary treatment for BPPV. Its 2015 clinical practice guidelines state explicitly that repositioning manoeuvres are the treatment of choice. The guidelines note that medication may be used short-term for severe nausea accompanying an acute episode, but not as the ongoing management strategy.

The problem in India is partly structural. A patient with sudden spinning goes to a general physician or a medicine specialist. That clinician may not have trained in vestibular assessment, may not have a treatment table configured for Dix-Hallpike, and may reasonably reach for a prescription that reduces the patient's distress at the next visit. The patient feels somewhat better on the medication, because the suppressant blunts the symptom, and continues taking it. The crystal stays in the canal. The vertigo returns whenever the medication wears off or the patient stops taking it.

If vertigo episodes are brief, triggered by specific head positions, and have been investigated enough to rule out cardiovascular or neurological causes, ask the clinician directly: has BPPV been considered, and has a Dix-Hallpike test been done? If the answer is no, ask for a referral to a neurologist or an ENT specialist with vestibular training, or to a physiotherapist who holds a vestibular rehabilitation qualification.

Vestibular physiotherapy is available in most tier-one Indian cities and in many tier-two cities, though access is uneven. The Epley manoeuvre is not a procedure that requires a hospital admission or general anaesthesia. It requires a trained pair of hands and a flat surface.

BPPV does occasionally resolve on its own, as the crystal dissolves or finds its way out of the canal without intervention. The Bárány Society guidelines acknowledge this. But spontaneous resolution can take weeks to months, during which the patient is restricted in movement, unable to drive safely, and at elevated fall risk, a serious concern for older adults. Waiting it out while on suppressants is not a neutral choice.

The vertigo that has been labelled chronic, or that has been managed with daily tablets for six months without a repositioning attempt, deserves a second look from a clinician who will first perform the test.