Why Vertigo Happens Even When Your Brain MRI Is Normal
July 29, 2026
Treatment for Benign Paroxysmal Positional Vertigo (BPPV) involves appropriate canaltih repositioning maneuvers, rather than relying on long-term anti-vertigo medicines.
It is highly effective when the correct diagnosis is made. The important part is identifying which semicircular canal inside the inner ear and which side are affected, because the right maneuver depends on the type of BPPV.
As an ENT and vertigo specialist in Vashi, Navi Mumbai, I assess the pattern of symptoms and perform appropriate positional testing before selecting the treatment.
BPPV is one of several causes of vertigo. My guide to vertigo causes and treatment might help you understand the broader picture.
BPPV is an inner-ear balance disorder that causes brief episodes of spinning vertigo triggered by certain position changes or head movements.
BPPV stands for Benign paroxysmal positional vertigo:
B – Benign: The condition feels scary but is not a dangerous condition.
P – Paroxysmal: Symptoms come in sudden, brief episodes
P– Positional: Triggered by changes in head position
V – Vertigo: A sensation that the surrounding is spinning
BPPV may also cause nausea, vomiting or involuntary eye movement called nystagmus.
For a detailed explanation of positional vertigo read my blog What is Positional vertigo?
Feeling dizzy when you wake up and turn over in bed, sit up or change head position frequently happens due to BPPV.
BPPV occurs when tiny calcium crystals, called otoconia, become displaced and enter a semicircular canal. When you move your head, these crystals can disturb the normal balance signals sent to the brain, causing a brief spinning sensation.
However, not all dizziness on waking is caused by BPPV. Low blood pressure, overnight dehydration, certain medications and other conditions can also cause dizziness or morning light-headedness.
If your morning dizziness is recurrent or occurs with other symptoms, evaluation by a vertigo specialist can help determine the cause and treatment.
In some cases, BPPV can resolve on its own within a few weeks. However, waiting for it to settle may mean experiencing repeated attacks of positional vertigo, anxiety and the risk of falls.
A canal-specific repositioning maneuver like Epley or Semont, performed by a trained ENT specialist or neurotologist, often brings faster relief from positional vertigo.
ENT specialists or neuro-otologists use a combination of clinical history, positional tests and balance assessments to determine:
A detailed history of symptoms is an important first step towards a correct diagnosis.
I will ask about the onset, duration and triggers of your dizziness, such as turning in bed, as well as whether the episodes are intermittent or constant. Associated symptoms such as nausea, hearing changes or tinnitus are also noted.
For BPPV diagnosis, a well-performed positional test is enough.
A vertigo specialist can determine the affected canal and side, by observing the direction, timing, and pattern of the eye movement during positional testing. It helps in planning correct canalith repositioning maneuver.
The Dix-Hallpike test is mainly used to diagnose posterior-canal BPPV.
During this test your head is turned 45 degrees to one side (sitting) and then moved into a specific lying position while the specialist observes for vertigo and nystagmus (involuntary eye movements).
The Supine Roll Test is used to detect lateral (horizontal)-canal BPPV.
The patient lies flat on their back and the head is turned quickly from side to side to check for vertigo and characteristic sideways eye-movements.
Supine head hanging test may be used to diagnose anterior semicircular (SSC) canal BPPV.
It involves positioning the head in extension (backward past the horizontal plane ) while the specialist observes for the characteristic nystagmus pattern.
These are not used to diagnose BPPV directly but they help assess vestibular function and rule out other conditions and central neurological red flags:
Pulse and blood pressure: BP and pulse in lying and standing position to check for POTS and postural hypertension
Advanced Vestibular tests like Videonystagmography (VNG) and Posturography, may be considered when diagnosis is unclear or positional nystagmus is not visible to the naked eyes.
CT or MRI is not routinely needed for BPPV. Imaging may be aqdvised if there are unsusual findings or symptoms suggest some brain disorder.
Relief From Positional Vertigo
The first step in BPPV treatment is accurately diagnosing the BPPV and identifying which semicircular canal is affected.
Next your ENT specialist will perform certain repositioning maneuver specific for that particular canal to bring immediate relief from positional vertigo.
The choice of maneuver depends on the affected canal.
These are specific head and body movements to move and reposit the displaced inner-ear crystals (called otoconia) back to the original location in the inner ear.
Different semicircular canals require different movement patterns, so the maneuver must match the specific type and side of BPPV.
These are guided by your vertigo specialist or vestibular therapist.
The Epley maneuver is commonly used for posterior-canal BPPV, which is the most frequent type of BPPV.
It involves turning your head and body through a specific sequence to move the displaced crystals out of the affected semicircular canal and back towards the vestibule.
It is performed in the clinic but in appropriate patients, a home version may also be taught after the affected side and diagnosis have been established.
It usually provides relief from spinning vertigo in 1–3 sessions
The Semont maneuver is another established alternative treatment for posterior-canal BPPV.
It involves moving the head and body rapidly from one side to the other to help reposition the displaced crystals.
The Gufoni and Appiani maneuvers are used for certain forms of horizontal (lateral) canal BPPV.
The appropriate maneuver depends on the specific horizontal-canal variant and the direction of the nystagmus identified during positional testing.
I use Lampert or Barbecue (BBQ) Roll maneuver as an alternative repositioning treatment option for horizontal-canal BPPV.
It involves moving patients’ body in sequence based on the side of canal involve to move displaced otoconia, based on the side affected.
Anterior-canal BPPV is less common than posterior- and horizontal-canal variants.
I use modified Yacovino or Deep Head-Hanging maneuver for anterior canal BPPV this canal.
Brandt-Daroff exercises are physical movements that can be performed at home in selected patients.
Unlike canalith repositioning maneuvers, these are not first line treatment for BPPV and do not directly reposition displaced crystals. Instead, they primarily help with residual motion sensitivity.
The frequency and duration should be individualized according to the patient’s symptoms and treatment plan.
Vestibular Rehabilitation Therapy (VRT) uses customized exercises to improve balance, gaze stability, and tolerance to movement.
It may be useful when dizziness or imbalance persists after BPPV treatment or when another overlapping vestibular problem is present.
After a successful canalith repositioning maneuver, many patients experience a significant improvement. Some patients may continue to feel mildly unsteady for a short period as the nervous system adapts.
If the first maneuver does not completely relieve your symptoms, it may need to be repeated or modified. The diagnosis and affected canal should be reassessed before deciding the next treatment.
Postural restrictions, such as sleeping upright or keeping the head in a rigid position, are not routinely recommended after BPPV treatment. However, your ENT specialist may give you temporary, individualized advice depending on your clinical situation.
BPPV is treatable when the diagnosis and affected canal are correctly identified. Problems can arise when dizziness is assumed to be BPPV without appropriate positional testing or when treatment focuses only on suppressing symptoms.
Medicines such as Betahistine, Cinnarizine, or Prochlorperazine may sometimes be prescribed for short-term relief of troublesome symptoms like nausea or severe acute vertigo.
However, these medicines do not reposition the displaced otoconia.
Think of it this way: If a bone is fractured and you are in pain, painkillers may reduce the pain, but they do not realign the bone. We need to fix the fracture Similarly, medicines may reduce some symptoms of BPPV, but they do not reposition the displaced otoconia.
I often see patients taking vestibular suppressants for weeks, or even months. This can suppress natural central compensation and delay recovery.
Online videos, Google and Chat GPT can make it tempting to perform an Epley maneuver as soon as dizziness occurs. However, not every type of positional vertigo is posterior-canal BPPV.
The correct maneuver depends on the affected canal and side. An Epley maneuver is inappropriate for horizontal or anterior variants.
Also, not all vertigo is positional vertigo. Vestibular migraine, Meniere’s disease, vestibular neuritis or postural hypotension can mimic BPPV.
Wrong diagnosis or wrong technique can worsen symptoms or trigger conditions like PPPD (Persistent Postural-Perceptual Dizziness).
As a neuro-otologist, I often see patients who’ve already consulted multiple general physicians, neurologists, or even ENTs but still not received a clear diagnosis or misdiagnosed as BPPV.
Common Diagnostic Gaps:
• Only performing the Dix-Hallpike test, which detects posterior canal BPPV
• Not checking for lateral or anterior canal involvement
• Not repeating positional tests if result is unclear or negative on the first attempt
• Not observing/recognizing nystagmus appropriately
For spinning vertigo or dizziness you may see an ENT specialist with experience in vestibular disorders, a neurotologist, or a vertigo specialist.
The doctor need to differentiate BPPV from other positional vertigo types, perform the appropriate positional tests, identify the affected semicircular canal and treat it.
See a specialist if:
There are several possible reasons for dizziness after BPPV treatment by repositioning maneuver:
Yes. BPPV can recur, even after successful treatment.
although the strength and consistency of evidence vary across factors and studies.
Evidence suggests recurrence is more likely in some people, particularly those with a history of migraine, older age, previous head injury, osteoporosis, hypertension, diabetes, hyperlipidemia, or low vitamin D levels.
With proper follow-up, daily home exercises, and lifestyle adjustments, most recurrences can be managed easily.
If you have recurrent BPPV, your doctor may consider checking your vitamin D level. Studies suggest that correcting vitamin D deficiency may reduce BPPV recurrence in some patients.
The evidence has become stronger with newer studies, although vitamin D is not a treatment for the acute BPPV episode itself.
BPPV can feel scary but with right diagnosis and treatment helps reliving symptoms.
If you feel spinning when you lie down, Visit our Navi Mumbai ENT clinic for expert vertigo treatment.
You can read my blog on Why do I feel dizzy when I lie down or turn in bed?
Our clinic specializes in vertigo diagnosis, advanced vestibular tests (VNG, Posturography) and maneuver-based treatments for BPPV and treatment of other balance disorders.
The Epley maneuver is a series of head and body movements used to reposition displaced inner ear crystals (otoconia) from affected semicircular canal back to their original location. It is commonly used to treat posterior canal BPPV.
Many patients experience a significant relief immediately after a successful repositioning maneuver. However, some may continue to feel mildly unsteady or sensitive to movement for a short time.
Some patients improve after one repositioning maneuver, while others may need repeat maneuvers over a few days.
The number of treatments depends on the how the treatment works and and whether multiple canals are involved..
If one Epley’s doesn’t work then your ENT will repeat it up to three times in the same session, depending upon the findings.
If symptoms still persist, your ENT will reassess the affected canal and side. You may have a different cause of vertigo, like vestibular migraine, have BPPV in a different canal or might be having cupulolithiais.
Epley is not recommended without a proper diagnosis. Doing it incorrectly or for the wrong canal can worsen symptoms.
An ENT specialist should guide you first, once the diagnosis and affected side is confirmed, you may be taught how to perform it carefully at home.
No. These medicines may reduce symptoms temporarily but do not treat the underlying cause of BPPV. The primary treatment of BPPV is an appropriate canalith repositioning maneuver.
If dizziness starts with specific head movement such as turning in bed, getting up, lying down or looking up, and if it feels like spinning that lasts for few sec to less than a minute BPPV could be the cause.
A simple Dix-Hallpike test at the clinic can confirm the diagnosis.
No, BPPV itself is not dangerous as. It doesn’t affect your brain or hearing. But sudden spinning can be the reason for falls especially in older adults so treatment is important.
It is important to get the correct diagnosis, especially if dizziness is prolonged, associated with other symptoms, or does not follow the typical pattern of BPPV.
Yes, in some cases BPPV can resolve naturally within a few weeks. However, treatment speeds recovery significantly and avoids unnecessary suffering.
Hi, I’m Dr. Archana Jhawar, an ENT & Vertigo specialist with 25 years of experience. I specialize in tinnitus, vertigo, ear, nose and throat care, and ENT surgeries. I practice at Neoalta Clinic, Vashi, and Kokilaben Dhirubhai Ambani Hospital in Navi Mumbai.
I have advanced training in vertigo management and REBT(CBT), combining evidence-based care with a compassionate approach. Beyond medicine, I enjoy reading, writing, music, yoga, and photography.
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