What are the key clinical features to consider when diagnosing Benign Paroxysmal Positional Vertigo (BPPV) in a primary care setting?

Key clinical features for diagnosing Benign Paroxysmal Positional Vertigo (BPPV) in primary care include:

• Sudden onset of brief episodes of vertigo triggered by specific changes in head position, such as turning over in bed or looking upwards.
• Vertigo is typically positional and transient, lasting less than a minute per episode.
• Observation of characteristic nystagmus (involuntary eye movements) during positional testing, such as the Dix-Hallpike manoeuvre, which is diagnostic if performed by a trained healthcare professional.
• Absence of other neurological signs or symptoms such as hearing loss, tinnitus, or focal neurological deficits, which may suggest alternative diagnoses.
• History may include recent head injury or labyrinthitis, which are common precipitating factors.
• Symptoms are often reproducible with positional changes and relieved by remaining still.

In primary care, if a healthcare professional trained in the Hallpike manoeuvre is available, it should be offered to confirm diagnosis. If BPPV is diagnosed, a canalith repositioning manoeuvre (e.g., Epley manoeuvre) can be offered if safe and feasible. Referral to a specialist is recommended if the diagnosis is uncertain, if there are atypical features, or if repositioning manoeuvres cannot be performed safely or fail to resolve symptoms.

Be cautious performing manoeuvres in patients with neck or back problems, unstable cardiac disease, or suspected vertebrobasilar insufficiency.

Overall, the diagnosis is clinical, based on history and positional testing, with exclusion of other causes of vertigo.

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