BPPV: Under Diagnosed Once Again

Last week, I reviewed a recent study from the journal Frontiers in Neurology demonstrating that nearly all (about 90%) of patients with complaints of dizziness or vertigo seen at a specialty vestibular clinic receive a firm diagnosis. This is much higher than any other diagnostic approach.

This week, let’s take a look at some of the specific diagnosis, and some of the conclusions put forth by the study authors. They report that BPPV, Vestibular Migraine, and multi-sensory dizziness are grossly under-diagnosed at the primary care level. They also point out that these three conditions have effective treatments once the diagnosis is made.

Benign Paroxysmal Positional Vertigo (BPPV)

The most under-diagnosed condition was BPPV. They found that 25% of patients referred had BPPV, when only 12 to 13% had received a preliminary diagnosis of BPPV. In essence, confirmed BPPV was twice as common as the PCP suspected.

[Editor’s note: The criteria for establishing a diagnosis of BPPV in this study was a positive Dix-Hallpike exam. We know that many patients with BPPV will have a negative exam when, in fact, BPPV is the cause of the symptoms that brought them in to the office. I suspect, therefore, that the actual number of patients with BPPV may be higher. I personally believe BPPV is grossly under-diagnosed at both the primary care and specialty levels]


Rather than risk misinterpreting or mischaracterizing the study author’s conclusions, I will simply print two sentences from their “discussion” section that say it all:

“Considering that nearly 45% of outpatients with dizziness are seen and treated by general practitioners or family physicians and that our study demonstrates a significant change in diagnoses of vertigo after referral to a specialized center, underlines the importance of increasing neuro-otological skills of primary care physicians.”

“ However, when diagnoses cannot be established with bedside tests alone, a referral to a specialized center should always be considered.”


Next week, some editorial ranting.





About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.