Dizziness: causes, assessment and BPPV

Dizziness is a collective term for a spinning sensation, a rocking sensation and similar experiences. NHI states that about 10 percent of Norwegians have problems with dizziness or poor balance, and that about one third of people over 65 have episodes of dizziness [1].

The causes are often grouped by where the problem arises: in the balance organ of the inner ear, in the brain or in the circulation, for example with low blood pressure. Side effects of medication, diabetes, thyroid disease and anaemia can also cause dizziness. Dizziness without a known cause is the most common form, and it is often transient [1].

BPPV stands for benign paroxysmal positional vertigo. The guideline describes it as a disorder of the inner ear with repeated episodes of positional vertigo. Patients describe brief attacks, usually under one minute, that come when they roll over in bed, look up or bend forward [2].

The main explanation is that loose particles, probably otoliths from the inner ear, end up in one of the semicircular canals, most often the posterior one. When the head moves, the particles create a fluid flow that triggers the dizziness [3]. The condition becomes more common with age, and the average age of patients is around 60 years [3].

Some experience unspecific unsteadiness or light-headedness rather than clear rotation. About half report unsteadiness between attacks as well [2].

The history is decisive. Blood pressure, heart, lungs, nerves and ears are then examined, among other things. Blood tests can help distinguish between possible causes, and when needed hearing tests, CT or MRI and specialised tests of balance and hearing are used [1].

When BPPV is suspected, positional tests are used. In posterior canal BPPV the Dix-Hallpike manoeuvre provokes characteristic eye movements (nystagmus) and dizziness after a short delay, and these usually fade within 10 to 20 seconds [3]. If the test gives no such findings but the history fits, the guideline recommends a supine roll test to check whether the lateral canal is involved [2].

The guideline does not recommend imaging or vestibular testing when the criteria for BPPV are met, unless other findings call for it [2].

For BPPV in the posterior canal the guideline recommends a repositioning manoeuvre, in which the head is moved through a series of positions to shift the particles out of the canal. The recommendation is strong, and referral to someone who performs the manoeuvre is also an option [2]. The Epley and Semont manoeuvres are the best known [3]. The treatment often gives immediate improvement [3].

The guideline does not recommend routine use of medicines that suppress dizziness. Observation with follow-up can be offered as an initial approach, and vestibular rehabilitation, alone or with a clinician, can be an alternative [2]. No particular restrictions on head position are recommended after repositioning [2].

The patient should be reassessed within one month to see whether the symptoms have resolved [2].

The symptoms often disappear on their own, but recurrence is common and can come after long symptom-free periods. Some have long-lasting problems. Repositioning seems to shorten the period with symptoms, but does not prevent recurrence [3].

The guideline points out that patients should be informed about the risk of recurrence and about safety in everyday life. Older people have a particularly increased risk of falls, and reduced balance should be included in the assessment [2].

Sudden and severe dizziness together with chest pain or paralysis may indicate a heart attack or stroke. The same applies to acute dizziness with reduced hearing or visual disturbances. In such cases you should seek help immediately [1].

If you suspect a stroke, call 113 straight away. Signs can include sudden weakness or numbness in the face, arm or leg, difficulty speaking, vision problems and problems with walking, balance or coordination. Symptoms that pass quickly may be a transient attack, and you should call 113 then as well [4].

For dizziness without signs of acute illness, a chiropractor with expertise in the field can go through the history and examine which type of dizziness it is. At Dr.Dropin Økern, VNG goggles are used, among other things. They film and magnify the eye movements, so that different forms of dizziness can be told apart and the right manoeuvre chosen. You can read more about BPPV and treatment of dizziness.

What is BPPV?

BPPV is a condition of the inner ear in which loose particles end up in a semicircular canal and cause short attacks of spinning dizziness with certain head movements [2][3].

How long does an attack of BPPV last?

The attacks are brief. The guideline states usually under one minute [2], and a Norwegian review article describes typically 10 to 30 seconds [3].

Can BPPV come back?

Yes. Recurrence is common and can come after long symptom-free periods [3].

Do I need an MRI for dizziness?

It depends on the findings. When the criteria for BPPV are met, the guideline does not recommend imaging unless other signs call for it [2]. For other forms of dizziness, CT or MRI may be relevant [1].

When is dizziness dangerous?

Sudden and severe dizziness together with chest pain, paralysis, reduced hearing or visual disturbances requires emergency help [1]. If you suspect a stroke, call 113 [4].

The page about headache and dizziness describes what an examination can involve. You can find more articles in the overview of articles.

This article was written by Dr.Dropin Fysikalske and is based on the sources listed below. It gives general information and does not replace an examination by a healthcare professional.

The websites were accessed and read on 22 October 2026.

1. Svimmelhet (dizziness: causes and assessment). NHI.no, based on Legehandboka. Last updated 22 July 2025. Link and link

2. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3S):S1-S47. doi:10.1177/0194599816689667. Link

3. Benign paroksysmal posisjonsvertigo (benign paroxysmal positional vertigo). Tidsskrift for Den norske legeforening, 2002. Link

4. Symptomer på hjerneslag (symptoms of stroke). NHI.no. Last updated 19 January 2023. Link