BPPV - benign paroxysmal positional vertigo - is the most common cause of vertigo.
The typical story: brief episodes of intense spinning triggered by specific head movements (rolling over in bed, looking up at a shelf, lying down).
Duration is seconds to a minute, not hours. Often worse first thing in the morning, improves with activity.
Despite how common it is - perhaps one in five lifetime incidence - BPPV remains widely undiagnosed and untreated in Johor.
Patients are frequently given cinnarizine or betahistine, sometimes for months, without anyone performing the specific diagnostic manoeuvre (Dix-Hallpike test) or the curative one (Epley or similar canalith repositioning).
A correctly performed repositioning procedure resolves around 85% of BPPV cases in one to two sessions.
How BPPV differs from other vertigo
Key distinguishing features:
- Positional trigger - vertigo only on specific head movements, not continuous.
- Short duration - each episode 30 seconds to 1 minute, not hours.
- Latency - often a few-second delay between the trigger movement and the spinning starting.
- No hearing changes - BPPV doesn't cause deafness or tinnitus. If hearing is affected, think Ménière's or vestibular neuritis.
- Fatigue with repetition - repeating the trigger movement reduces the intensity each time.
The diagnostic test: Dix-Hallpike
In the Dix-Hallpike manoeuvre, the patient sits on the treatment bench with their head turned 45° toward the suspected affected side.
The clinician lowers them quickly backwards into a head-hanging position.
If posterior canal BPPV is present, the patient experiences brief intense vertigo with a specific eye movement pattern (upbeating, torsional nystagmus) after a 2–10 second latency.
This test done properly confirms the diagnosis in 90%+ of posterior canal cases. Horizontal canal BPPV uses a different test (supine roll test).
A neurologist or vestibular physiotherapist is trained to perform these.
The treatment: canalith repositioning
The Epley manoeuvre (for posterior canal) takes about 5 minutes to perform.
The clinician guides the patient through a specific sequence of head positions that moves the displaced otoconia (tiny crystals in the inner ear) out of the semicircular canal and back to where they belong.
One Epley manoeuvre resolves approximately 70% of posterior canal BPPV in a single session. A second session the following week resolves most of the remainder.
Horizontal canal BPPV uses different manoeuvres (Gufoni or Lempert log-roll).
Post-procedure instructions
Advice we give after successful Epley:
- Sleep propped up at 45° for 1–2 nights.
- Avoid the trigger movements (rolling toward the treated side, tilting head dramatically) for 48 hours.
- Return if symptoms recur - BPPV can recur in 15–25% within the first year.
Other causes of vertigo we don't treat
Physiotherapy doesn't fix:
- Ménière's disease - episodes with hearing loss and fullness. ENT referral.
- Central vertigo - from stroke, tumour, or migraine. Neurological referral.
- Vestibular neuritis or labyrinthitis - these get vestibular rehabilitation (a different, longer protocol), not repositioning.
Vestibular rehabilitation for non-BPPV conditions
For vestibular neuritis, post-concussion dizziness, persistent postural perceptual dizziness, or bilateral vestibular loss, the treatment is graded exposure to movements that provoke dizziness.
The brain adapts. Typical programme:
- Gaze stabilisation - focus on a target while moving the head.
- Habituation - repeated provoking movements to desensitise the system.
- Balance retraining - progressive from stable to dynamic.
- Functional integration - return to driving, work, sport.
Runs 4–8 weeks for most cases.
Typical Johor costs
- Dix-Hallpike + Epley session: RM120-250 for a single visit.
- Vestibular rehabilitation course: 6–10 sessions at RM120-250.
- Medical workup (ENT, audiogram if hearing issues): separate pathway.
How PhysioJohor matches vertigo patients
WhatsApp us with: how long symptoms have been present, specific triggers (rolling in bed, looking up), duration of each episode, any hearing changes, and any recent viral illness or head impact.
We match to a vestibular-trained physiotherapist - not all physios are. One successful repositioning session often resolves months of disability.
Related guide: Physiotherapy in Johor - complete guide