Positional Vertigo: Exercises, Causes, Symptoms, and Diagnosis

If you suffer from any or all of the symptoms mentioned hereunder, we recommend that you consult with your healthcare provider. Always seek the advice of a physician or other qualified healthcare provider with any questions regarding a medical condition.

What is Positional Vertigo? 

People who suffer from vertigo define it as the sensation that you or your surroundings are spinning. For some people, the feeling may be slight and barely noticeable. For others, the vertigo attacks can be so severe that it can be impossible to keep balance and carry on daily activities.  In rare cases, vertigo can be constant and last for days, making it difficult to do simple tasks like getting up, walking or sitting down.

How inner ear balance plays a role in this condition

Our ears are not only responsible for our hearing. Inside our ears is an entire system responsible for our body’s balance called the vestibular system. The system includes three semicircular canals with fluid, which react when you rotate your head. When you turn your head, the inner ear turns with it, and the fluid acts as a balance to prevent you from getting dizzy.

Image credit: Cleveland Clinic

Vertigo is commonly caused by issues in the balance system in the inner ear. It could be an issue with the vestibular nerves or the calcium crystals in the inner ear.

What are the Common Causes of Positional Vertigo

As we said before, vertigo is a symptom of an underlying condition. What are some of the most common conditions causing vertigo?

• Vestibular neuritis: 

Vestibular neuritis is a common condition in adults. It is an inflammation of the nerves in the inner ear’s balance section. Patients suffering from vestibular neuritis often experience nausea and have difficulty walking. Once the infection is resolved, the symptoms typically go away.

• Benign paroxysmal positional vertigo (BPPV)

The most common balance problem in adults happens when the calcium crystals in your inner ear are out of place. People with positional vertigo will experience a sensation that they are falling when turning in bed,  often described as “going over” or when you move your head back to look up.

• Migraines

A percentage of migraine sufferers also experience balance problems, like dizziness. This condition is called vestibular migraine. One common side effect of migraine is motion sickness.

• Persistent postural-perceptual dizziness

This condition often accompanies other types of vertigo. The symptoms usually include a sensation of motion in the head, which worsens when you look at objects in movement, such as in a car or a busy place, like a downtown street or a shopping mall.

• Meniere disease

This rare disease typically shows symptoms in people between 20 and 40. Meniere’s disease causes sudden vertigo that can be severe, hearing loss and tinnitus. Sadly, scientists don’t know yet what causes Meniere's disease.

• Acoustic Neuroma

Another rare condition is caused when a benign tumour grows on the nerve responsible for balance. The most common symptoms are hearing loss, tinnitus, dizziness and loss of balance.

Recognising Symptoms of Positional Vertigo

How do you know you have positional vertigo? Here is a list of common symptoms experienced during vertigo episodes:

• The feeling of spinning or moving
• Feeling the world is spinning around you
• Balance trouble
• Hearing loss
• Nausea and vomiting

BPPV happens when the calcium crystals called otoconia are not in the utricle and flow in the fluid-filled semicircular canals (SCC) that react to the rotation of the head. Positional vertigo can affect people of all ages, but it is more prevalent in adults over 50. In older patients, it can lead to falls and fractures.

Differentiating Positional Vertigo from Other Balance Disorders

Benign paroxysmal positional vertigo is a common inner ear disorder, with 20% of dizziness having BPPV.  Many conditions can cause dizziness. So, how to be sure it is BPPV and not another inner ear disorder?

• BPPV doesn’t cause problems in the nervous system—for instance, migraines, speech problems, or loss of control of the limbs. 
• BPPV doesn’t usually cause hearing loss.

The mark of Bening Positional Vertigo is called positional nystagmus, a rapid eye movement when experiencing a vertigo episode.

How Does a GP Give a Diagnosis of Positional Vertigo?

If you are experiencing dizziness and vertigo episodes, the first step is to go to a general practitioner or Ear-Nose-and-Throat to get a diagnosis. 

As we said before, the loose crystals don’t present a problem until the patient moves his head. When the patient looks up or down or changes positions in bed, the crystals move in the canal, causing vertigo and rapid eye movement, called nystagmus.

What are the medical evaluations and tests used for accurate diagnosis of BBPV?

The doctor will confirm the nystagmus by doing a Dix-Hallpike manoeuvre test. 

1. When sitting up, the doctor will turn the person’s head 45 degrees to one side. 
2. The patient is quickly laid down backwards with the head just at the edge of the examination table. 
3. This move often brings vertigo, and the doctor can confirm if there is nystagmus, confirming BPPV. 

If you have vertigo when tilting your head to the right, your right ear is affected. When to the left, your left ear is the one concerned. 

If you are experiencing vertigo, it is essential to consult a healthcare professional so he can rule out other conditions that present dizziness and prescribe treatment.  

Home Exercises for Positional Vertigo

The spinning sensation of vertigo can be debilitating and limit your daily activities. Depending on your case, there can be practical exercises to alleviate vertigo symptoms. 

The following sections explain step-by-step instructions for performing the exercises.

Epley Maneuver: A Widely Used Technique

The Epley is a popular way to accommodate the crystals back in place, and it is simple enough to do in your own home. However, your doctor must show you how to do the steps appropriately. Doing the Epley manoeuvre without proper instruction can cause vomiting and artery compression. 

Check this video to see a practitioner doing this manoeuvre: Epley Maneuver to Treat BPPV Vertigo 

How to perform the Epley manoeuvre at home?

You should do the manoeuvre for the side the affected ear is (right side for the right ear and vice versa). Here, we’ll give an example for the right ear: 

1. Sit on the edge of the bed. Put the pillow so it lays under your shoulders when you lie down. Turn your head 45 degrees to the right while sitting. 
2. Quickly lie down on your back with your head still at the 45-degree angle. Wait until any vertigo stops. 
3. Turn your head 90 degrees to the left without raising it. Wait 30 seconds. 
4. Turn on your side, to the right, with your head and body. Wait 30 seconds. 
5. Slowly sit up but stay on the bed for a few minutes. 

If the left ear is affected, reverse the instructions. Repeat three times before sleep until the vertigo is gone for 24 hours. 

Brandt-Daroff Exercises for Vertigo Relief

These are a group of movements often used to treat BPPV. Advocates of this method claim the exercises can break up and move the calcium crystals back to their place. 
Here, you can see a practitioner performing the exercises: Brandt-Daroff

If you want to try it, here are the Instructions for incorporating Brandt-Daroff exercises into your daily routine.

How to perform the Brandt-Daroff exercises in your home:

1.  Sit up on the edge of your bed
2. Lie down on your right side, turning your head to look up while lying down. 
3. Keep your head up at 45 degrees for 30 seconds. 
4. Sit up for 30 seconds.
5. Repeat these steps on the other side
6. Repeat the whole series four more times. 
7. Sit up. If there is any vertigo, wait until it passes.

Vestibular Rehabilitation Therapy (VRT)

In many cases, vestibular rehabilitation therapy can help manage the positional vertigo. The exercises improve your balance and reduce vertigo symptoms. Benign cases, like BPPV, only require a few sessions. More complex problems, such as vestibular neuritis or Meniere, may require weeks or months to see improvement.

How does vestibular rehabilitation therapy work?

The sense of balance relies on the connection between the nervous and sensory systems. Concretely, the relationship between the inner ear's vestibular system, the vision and the body’s tissues, such as skin, joints and muscles. When something disrupts

With this connection, you experience vertigo and dizziness. 

It is essential to seek professional guidance for VRT exercises to do them correctly. Before starting therapy, you may visit an audiologist for a series of vestibular tests. These tests evaluate how your vestibular system works. Then, you may have to go to a physical therapist to assess your balance, flexibility, walking stability and strength. 

Vestibular rehabilitation usually consists of three parts:

• Learning to control eye movemen

• Retraining the balance system

• Stretching and strengthening

Here is an example of vestibular exercises: Home Vestibular Exercises

You may expect some dizziness during the first sessions. That’s why we recommend to have another person accompany you. You should do them three times daily for at least six weeks until the vertigo disappears. You shouldn’t stop treatment before the symptoms stop because you can relapse.

Vestibular exercises

Do these exercises two or three times a day. Here are some tips for success: 

1. Try to do each movement 20 times. Start slowly and build up speed over time. 
2. Continue the exercises even if you get dizzy. Pause if you become nauseous. 
3. If the exercises make you sick, you can postpone it to the next session. 

Head exercises

1. While sitting, lower your head to look at the floor and then up to the ceiling. 
2. Repeat ten times. If you get dizzy, stop and wait 30 seconds until the vertigo resolves. 
3. Repeat two more times. 
4. Turn your head side to side, leading with your eyes. Turn your head fast enough to generate symptoms. 
5. Repeat ten times. Then, wait for symptoms to resolve. 

Sitting

1. Shrug your shoulders 20 times
2. Turn shoulders right and left 20 times
3. Rotate upper body right to left with eyes open 20 times, then with eyes closed. 
4. Bend forward and touch the floor, then sit up while looking at the wall 20 times. 
5. Bend forward and touch the ground, then sit up while moving your eyes to the floor and back 20 times. 
6. Follow your finger with your eyes: 
   1. Up and down
   2. Side to side
   3. Touch the finger to the tip of your nose and out.

Standing

1. Change from sitting to standing and back 20 times with your eyes open and 20 times with your eyes closed. 
2. Practice “heel to toe” while standing in a corner for 30 seconds with your eyes open. 
3. Try to stand without touching the wall. Then, try to stand on a cushion without touching the wall for 30 seconds. 
4. You may progress by standing with heels together, standing on one foot, and throwing a small ball from hand to hand. 

Walking

1. Walk straight for 5 minutes with one foot in front of the other.
2. Walk in a straight line, turning your head and eyes left and right. Turn left when stepping with your left foot and vice versa with your right. 
3. Repeat the process three times. 
4. Repeat while looking at the floor, then repeat while looking at the ceiling. 

Other exercises involve stabilising your gaze. You can find the entire series of vestibular exercises here: here. 

When should you stop your exercise? Experts recommend you stop your exercises for vertigo when symptoms stop for two weeks straight.

Lifestyle and Home Remedies for Positional Vertigo

Besides doing the exercises, there are several dietary and lifestyle changes for vertigo relief. From managing your stress to changes in your diet, here are some tips that can help you manage vertigo daily. 

• Ginkgo biloba - Studies show this extract can help and prescribe medication to treat vertigo symptoms. Take 240 milligrams of ginkgo biloba each day to lessen symptoms.
• Yoga - It is known to reduce stress and increase flexibility and balance with continuous practice. Start with simple poses, then add balance and bending forward poses. 
• Sleep and hydration - Stress, sleep deprivation and lack of hydration can trigger vertigo symptoms. 
• Vitamin D - A study suggests that a lack of vitamin D worsens symptoms of vertigo. 
• Avoid alcohol - Alcohol can dehydrate you and change the fluid composition in your inner ear, exacerbating the vertigo symptoms.

When to Seek Medical Attention?

Indications of severe vertigo requiring immediate medical attention:

If your vertigo episode comes accompanied by the following symptoms, it is time to seek immediate medical attention: 

• Difficulty speaking or slurred speech
• Numbness or weakness in the face or limbs
• Clumsiness or tremors
• Double vision or blurred vision

Recognising potential complications of positional vertigo

Although positional vertigo is benign, there can be some complications. Patients can experience nausea and vomiting. Vertigo episodes can also increase the chance of falling and fractures.

Medications and Treatments for Positional Vertigo

Positional vertigo usually doesn’t require medications. Sometimes, if the patient cannot take the reposition manoeuvres or has extreme nausea, the doctor may prescribe anti-nausea medication. 

If the vertigo is severe and persistent, the doctor may prescribe vestibulosuppresant medication. Other available treatment options for symptom management include antihistamines and antiemetic medication.

Preventive Measures for Positional Vertigo

There are some steps you can take to reduce the risk of vertigo episodes:

• Sleep with your head elevated.
• Move slowly when performing movements that can trigger vertigo. 
• If you feel dizzy, sit down. 
• Focusing on a single spot can help retrain your eyes and stop the dizziness if the vertigo episode happens in a public place. 
• Lying down in a dark, quiet room can help stop the vertigo. 

Can you cure vertigo?

Unfortunately, there is no cure for positional vertigo. However, following the exercises and tips can help manage symptoms and delay recurring episodes. 

Seeking a healthcare professional can give you personalised treatment for your symptoms. If you experience any of the symptoms mentioned in this article, please consult your general practitioner.