Introduction

Post-traumatic benign paroxysmal positional vertigo (BPPV) is a common but often overlooked consequence of concussions and mild traumatic brain injuries (TBIs). Many individuals recovering from a concussion experience dizziness, imbalance, and vertigo, which may be due to BPPV. Recognizing and treating post-traumatic BPPV is essential for a smoother recovery and a return to daily activities.

What is BPPV?

BPPV is a vestibular disorder caused by displaced calcium carbonate crystals (otoconia) in the inner ear. These crystals, which normally reside in the utricle, can move into the semicircular canals due to head trauma, leading to brief but intense episodes of vertigo triggered by head movements. While idiopathic BPPV primarily affects older adults, post-traumatic BPPV can affect individuals of all ages, particularly those who have sustained a concussion.

Incidence of Post-Traumatic BPPV After Concussion

Research suggests that post-traumatic BPPV is more common than many clinicians realize. Studies indicate that:

• Up to 57% of patients with traumatic brain injury (TBI) develop BPPV, particularly in cases of mild TBI or concussion (Zalewski et al.).
• BPPV accounts for approximately 21% of dizziness cases following mild to moderate head trauma (Eftekhari et al.).
• Post-traumatic BPPV tends to be more persistent and resistant to standard repositioning maneuvers, often requiring multiple treatments compared to idiopathic BPPV (Shin et al.).

Symptoms of Post-Traumatic BPPV

Individuals with post-traumatic BPPV may experience:

• Brief episodes of spinning vertigo triggered by head movements (e.g., rolling over in bed, looking up or down).
• Nausea or motion sensitivity.
• Difficulty with balance and spatial orientation.
• Increased risk of falls, particularly in older adults or individuals with additional vestibular dysfunction.

Diagnosis of Post-Traumatic BPPV

Diagnosis of BPPV is based on a clinical assessment that includes:

• Dix-Hallpike Maneuver: Used to diagnose posterior canal BPPV by observing characteristic nystagmus (involuntary eye movements).
• Supine Roll Test: Helps identify lateral canal BPPV, which is more commonly associated with trauma.
• Comprehensive Vestibular Examination: To rule out other vestibular disorders that may coexist with BPPV, such as vestibular migraines or post-concussive dizziness.

Treatment and Rehabilitation

The primary treatment for BPPV involves canalith repositioning maneuvers (CRMs), which help guide the displaced otoconia back into the utricle. Common techniques include:

• Epley Maneuver: Effective for posterior canal BPPV.
• Lempert (BBQ) Roll Maneuver: Used for lateral canal BPPV, which may be more prevalent in post-traumatic cases.
• Brandt-Daroff Exercises: Often prescribed for home treatment if residual dizziness persists.

For individuals recovering from a concussion, vestibular rehabilitation therapy (VRT) may be necessary to address lingering imbalance, motion sensitivity, and visual-vestibular integration issues.

Prognosis and Recovery

While idiopathic BPPV often resolves quickly with repositioning maneuvers, post-traumatic BPPV may require multiple treatments and a longer recovery period. Patients with coexisting post-concussion syndrome may experience persistent dizziness even after successful BPPV treatment, requiring additional vestibular therapy and accommodations.

Conclusion

Post-traumatic BPPV is a significant but treatable cause of dizziness following a concussion. Early recognition and proper management can help individuals regain their balance and quality of life. If you or someone you know is experiencing dizziness after a head injury, consider seeking evaluation by a vestibular specialist.

References

• Zalewski, Christopher, et al. “Vestibular Dysfunction in Traumatic Brain Injury: A Review of Current Understanding.” Frontiers in Neurology, vol. 12, 2021, article 718318. Frontiers
• Eftekhari, S., et al. “Benign Paroxysmal Positional Vertigo Following Mild Head Trauma: A Prospective Study.” The Laryngoscope, vol. 132, no. 3, 2022, pp. 567-573. Wiley Online Library
• Shin, J. E., et al. “Traumatic Brain Injury and the Development of Benign Paroxysmal Positional Vertigo: A Multicenter Study.” BMJ Neurology Open, vol. 6, no. 1, 2024, e000598. BMJ