There’s a chance that once you get past age 50, one morning you’ll roll over in bed and suddenly the world will start spinning madly. Imagine the worst case of the rolls you ever suffered during your college drinking days, and then imagine it a bit worse. This is an extremely nasty sensation and also terrifying. “The first time it happened to me, my husband and I both assumed I was having a stroke, and we went to the ER,” Elizabeth Carroll, a teacher in Nyack, New York, said. Carroll’s response is far from unusual. She felt “off balance,” and dizziness is one indication that a stroke has occurred. She was kept in the hospital for several days and given a CT scan.
It was only after she was discharged and referred to a neurologist that Carroll learned that she suffered from benign paroxysmal positional vertigo, which, as its name indicates, is a far less serious disorder than a stroke. This condition can, in most cases, be easily corrected without drugs or expensive tests. People with BPPV can often effectively treat the condition on their own at home by doing a series of physical maneuvers, or a doctor or physical therapist can help them perform the movements in their office. Yet, for reasons not entirely clear, neither BPPV nor this fast, easy, inexpensive method for treating it is well known to the general public. Even more puzzling is the stubborn lack of awareness about both among medical professionals.
I was lucky. The first time I flopped over in bed one morning and felt like a washing machine drum on spin cycle, I had a pretty good idea what was going on. A few months earlier, I’d had lunch with my friend Maria, who recounted her own sudden case of vertigo. Her husband had done an internet search and come up with links to YouTube videos about how to perform something called the Epley maneuver, and decided they should try it. The maneuver—which involves first turning the sufferer’s head to the side at an angle halfway between face-forward and completely over the shoulder, then leaning the person backward on a bed or other surface so that their head and neck drop off the edge, and then conducting a series of other similar movements—worked miraculously. How strange and amazing, we both agreed, that an affliction that felt so catastrophic could be so easily cured.
When my spin cycle started, I at first tried to stay motionless. It’s typical of BPPV that movement, particularly of the head, will trigger it and that remaining still will cause it to temporarily subside. Then, I reached for my iPad and feebly typed in “vertigo maneuver,” since I couldn’t remember the name of the doctor, John M. Epley, who invented it. I found the same videos Maria’s husband had, and followed their instructions myself. While it’s surely better to perform the maneuver with professional help, it is quite possible to do it on your own. Apart from a faint sensation of lightheadedness that dissipated by the end of the day, my vertigo was cured.
The next year, it happened again, and this time it took several performances of the maneuver to get to the point where I could walk without worrying I’d pitch sideways into a wall. Maybe I wasn’t doing it properly? I decided to call the telehealth service offered by my insurance. That doctor prescribed meclizine, an anti-nausea drug, which, although it didn’t stop the vertigo, did make me feel a little better, since I’ve always been prone to motion sickness. But she never mentioned the Epley maneuver or any of the other maneuvers developed to treat BPPV. I made an appointment with my GP and saw a physician assistant there.
“This isn’t working quite as well for me as it did the first time,” I told him. “I thought maybe if someone else could guide me through the maneuver, I’d have a better sense of whether I’m doing it right.”
“If what you’ve been doing has worked for you,” he replied, “I’m sure you’re doing it right.”
I had the distinct impression that he had no idea what I was talking about. Over time, I’d learn of other BPPV sufferers who found more relief from word-of-mouth with friends and YouTube than from medical professionals.
“Your experience is very common,” Dr. Jonathan Edlow, professor of medicine and emergency medicine at Harvard Medical School, told me. “Despite the fact that BPPV is also incredibly common, it’s remarkably poorly understood by many, if not most, medical physicians and PAs, and that’s true whether they’re emergency physicians or internal medicine doctors.” The author of several papers on how emergency room physicians should diagnose patients presenting with vertigo, Edlow, who is 70, marveled, “When I went to medical school a long, long time ago, I don’t remember being taught about it, and I think the first 20 years of being in an emergency position, I can’t remember ever diagnosing it.” Now that he’s aware of BPPV, he said, he spots it around 10 times a year. The condition is more common in older people, but it’s not exclusive to them.
In a 2022 paper titled “Acute dizziness: A personal journey through a paradigm shift,” Edlow describes a transformation in emergency medicine protocol from one that focused on “symptom quality”—that is, on asking the patient to better define what they mean by “dizzy”—to one that zeroes in on “timing and triggers”: what events or actions, such as rolling over in bed, preceded the dizzy spell, how long it lasts, and in what circumstances it subsides. BPPV is “a fairly common diagnosis,” said Dr. Neil Bhattacharyya, professor of otolaryngology at Massachusetts Eye and Ear and Harvard Medical School. In 2008 Bhattacharyya was part of a panel of experts selected by the American Academy of Otolaryngology to write a set of clinical practice guidelines for diagnosing and treating BPPV. He cautioned that vertigo can have other causes and patients should consult a doctor, ideally after “keeping a diary of their symptoms, such as ‘Rolled over in bed, had 30 seconds of dizziness, went away, was fine the rest of the day.’ ” Bhattacharyya stressed, “For somebody over 65 who believes they have BPPV, you still do need to see a provider who can diagnose and rule out other potential serious causes.
“I’m just disappointed and surprised,” said Bhattacharyya when I told him about my experience seeking treatment for BPPV.
Being aware of the characteristic symptoms of BPPV can help patients be their own advocates, and can prevent physicians from recommending expensive diagnostic tests such as MRI or CT scans, which cannot detect BPPV, and meclizine or other vestibular suppressants, which often have unwanted side effects, in addition to not being effective against the vertigo itself. Edlow is the co-author of a systematic review of randomized controlled trials that concluded, “These data suggest that a canalith repositioning maneuver, and not vestibular suppressants, should be the primary treatment for benign paroxysmal positional vertigo.”
What exactly does a canalith repositioning maneuver, like the Epley, do? BPPV occurs when canaliths—tiny particles of calcium carbonate sometimes informally referred to as “ear rocks”—escape from one part of the inner ear into one of the semicircular canals filled with fluid that play a key role in the vestibular system, which maintains our sense of balance and our position in space. Changes in head position can shift the canaliths in the fluid, causing it to send disorienting signals to the brain. The Epley maneuver is designed to guide the ear rocks out of the canal, a bit like those puzzle toys you tilt to roll a ball bearing through an enclosed maze.
Researchers believe that the majority of BPPV case are caused by canaliths in the posterior canal, where gravity is most likely to cause the particles to settle, but canaliths can also make their way into the inner ear’s horizontal or (most rarely) anterior canals. In the latter two cases, the Epley maneuver may be less effective, but other similar treatments—the Semont maneuver, the half-somersault maneuver, and the Yacovino maneuver—may be of more help. Note that all of these methods are maneuvers—that is, they involve the mechanical manipulation of the patient’s head to redirect the canaliths from the canals back to the parts of the ear where they won’t cause symptoms.
John Epley, the Oregon ear surgeon who invented the maneuver that bears his name, first developed the treatment in the late 1970s, but he did not initially find a receptive audience among his fellow otolaryngologists. According to a 2019 profile in the Oregonian, Epley’s demonstration of the maneuver at a 1980 conference was greeted with walkouts and a comment card from one doctor reading, “I resent having to waste my time listening to some guy’s pet theory.” For years, even Epley’s successful executions of the maneuver on patients resulted in skepticism and formal complaints. Epley struggled to publish the paper he wrote about the maneuver for a decade before it was finally accepted by the journal of the American Academy of Otolaryngology in 1992; even after that, resistance to the method lingered.
I asked Edlow why it has been so difficult to establish as common practice a simple, easy, nonpharmaceutical therapy for a common debilitating condition. “It’s human nature that people don’t like to have changes in their construct of reality,” he said. He likened Epley’s travails to those of Barry J. Marshall, who in the 1980s discovered the bacterium that causes peptic ulcers. “It took him 10 years to get his stuff published because we all thought it was Type A personalities and acid in the stomach, and we prescribed all these antacids. Now we’ve completely turned upside down our notion of what causes peptic ulcers.” Marshall, with J. Robin Warren, received the 2005 Nobel Prize in medicine for his work in this area, and there have certainly been times, after the spinning blessedly stopped, when I’ve felt that Epley, who died in 2019, deserved the same honor.
Edlow feels that medical professionals who don’t know about or, for some reason, don’t like the maneuver are missing out on an exceptional clinical experience. First, the treatment is elegant because the initial stage of the maneuver, when the sufferer’s head is tilted back at a 45 degree angle toward the affected ear, is also a diagnostic tool. The positioning, also known as the Dix-Hallpike test, briefly re-triggers the vertigo, causing a rapid eye-flicking called nystagmus, which confirms that the patient is suffering from BPPV. Second, Edlow says, using the maneuver to treat BPPV is “so much fun. There’s very little in medicine where you do a maneuver, a physical thing, and you fix the problem and you don’t need an X-ray and you don’t need blood tests and you don’t need a consultant. It’s enormously satisfying, both for the patient and for the physician.”