Benign Paroxysmal Positional Vertigo and Pain

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The MSK physician should be familiar with Benign Paroxysmal Positional Vertigo (BPPV). This is because in chronic BPPV the majority of patients have pain as a major symptom, with 87% of cases in one series. Furthermore, trauma is a major cause of BPPV in those under 50. Remembering that BPPV comes on with neck movements, it is easy to see how a misdiagnosis of "cervical vertigo" can be made when there is a history of trauma and neck pain.

Mechanisms of Pain

Postural control is primarily maintained through vestibulo-spinal and vestibulo-reticular reflexes, which aim to ensure vertical balance by modulating muscle tension in the neck, torso, and extremities. In conditions like Benign Paroxysmal Positional Vertigo (BPPV), movement of the head can trigger otoliths in the semicircular canals, leading to postural mismatches. Individuals often compensate for this imbalance through static muscle use, which can accumulate pain-inducing substances like arachnoid acid, bradykinin, and histamine. This pain subsequently disrupts motor control. Additionally, deficits in proprioception can delay protective neuromuscular reflexes, leading to potential joint damage and abnormal movement patterns. The high density of gamma-muscle spindles in the cranio-cervical joint, crucial for optimal motor control, further underscores the importance of proprioception in maintaining postural control and preventing pain.

Diagnosis

Patients with chronic neck pain and episodic dizziness should generally have semicircular canal testing - Dix-Hallpike for posterior canal at minimum. Supine roll is done for horizontal canal testing which is the second most common type. Anterior canal is very rare.

Treatment

Treatment of the BPPV may resolve the pain.

See Also

See https://dizziness-and-balance.com/disorders/bppv/bppv.html.