Étourdissements (VPPB)

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the person’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada 2018).
  
• Informations sociodémographiques : age, sex, gender identity, language, occupation, caregiving responsibilities and factors that affect balance, mobility, access or communication.

Principales préoccupations

• Timing and course: onset, frequency, duration, progression, symptom-free intervals, prior episodes and whether symptoms are continuous, spontaneous episodic or triggered episodic.
• Triggers and position: rolling in bed, lying back, getting up, looking up, bending, rapid head movement, standing, exertion, coughing, sound, busy visual environments or no clear trigger.
• Symptom experience: spinning or motion illusion, lightheadedness, near-fainting, imbalance, rocking, visual blurring with head movement, nausea and the person’s own description without forcing symptoms into one category.
• Neurological and head or neck symptoms: new weakness, numbness, facial asymmetry, speech or swallowing change, diplopia or visual field change, severe gait or coordination difficulty, new severe headache, new unusual neck or facial pain, a new drooping eyelid with a smaller pupil on the same side, loss of consciousness or seizure-like activity.
• Ear and migraine symptoms: sudden, fluctuating or progressive hearing change; tinnitus, ear fullness or pain; recent infection; migraine history; photophobia, phonophobia or aura.
• Cardiovascular and systemic symptoms: syncope or near-syncope, palpitations, chest pain, shortness of breath, exertional symptoms, orthostatic symptoms, fever, dehydration, bleeding or acute illness.
• Fonctionnement et participation aux activités : falls or near-falls, gait and transfer safety, mobility aids, driving, work, school, caregiving, sleep, physical activity, movement avoidance and confidence.
• Revue des systèmes corporels : neurological, cardiovascular, vestibular and auditory, visual, musculoskeletal, endocrine and metabolic, and other systems suggested by the presentation.
• Santé, mode de vie et histoire : stroke or transient ischemic attack, migraine, cardiovascular disease, diabetes, osteoporosis, vestibular or hearing disorder, head or neck trauma, infection, surgery, prolonged immobilization, sleep, physical activity, alcohol and substance use.
• Révision de la médication : prescription, non-prescription and substance use that may contribute to dizziness, sedation, blood-pressure change, bleeding risk or falls; recent starts, stops or dose changes; prior vestibular suppressants and response.
• Déterminants sociaux de la santé : housing and fall hazards, transportation, access to timely medical or vestibular care, finances, work flexibility, caregiving, social support and other factors that may shape safety and participation (Public Health Agency of Canada 2026).
• Previous assessment and care: prior positional testing, diagnoses, imaging, hearing or vestibular assessment, repositioning procedures, rehabilitation, medication, benefit, adverse effects and recurrence.
• Point de vue du patient : understanding of the symptoms, priorities, preferences, cultural context, concerns, expectations, acceptable symptom provocation and previous care experiences.
• Signaler un avis : Vérifiez les signaux d'alerte et référez-vous aux modules distincts « Signaux d'alerte orange » et « Signaux d'alerte jaune » lorsque cela est pertinent.

Mesures des résultats

• Use measures that are meaningful to the patient and practical to repeat. Record a baseline and reassess often enough to guide decisions.
• Fonctionnement propre au patient : Échelle fonctionnelle propre au patient (PSFS).
• Handicap et participation : Échelle d'évaluation du handicap de l'OMS 2.0 (WHODAS 2.0).
• Qualité de vie : WHO Quality of Life-BREF (WHOQOL-BREF).
• Dizziness-related impact: Dizziness Handicap Inventory (DHI) when a condition-specific measure is useful and practical to repeat.
• Falls and symptom pattern: record falls or near-falls and a consistent measure of episode frequency, duration or activity tolerance when these are decision-relevant.
• Objectifs individuels : agree on patient-defined goals and how progress will be recognized. SMART wording may be used.

Les signaux d'alerte orange indiquent qu'un problème de santé mentale ou de toxicomanie peut nécessiter une évaluation d'urgence ou rapide, voire une prise en charge partagée, et peut influencer la prise en charge musculo-squelettique. Ce n'est pas un diagnostic. En cas d'inquiétude, posez des questions directes et respectueuses en tenant compte de la sécurité immédiate, de la gravité du problème, de tout changement par rapport au fonctionnement quotidien habituel et du contexte. Les facteurs psychosociaux susceptibles d’affecter le rétablissement, mais ne nécessitant pas d’évaluation médicale ou psychiatrique distincte, sont abordés sous la rubrique « Signaux d’alerte jaune ».

ACTION : Organisez immédiatement une évaluation d'urgence en cas de danger immédiat ou de besoin médical urgent :

• Suicide, automutilation ou violence envers autrui : intention ou plan actuel, tentative récente, incapacité à rester en sécurité ou comportement suggérant un risque immédiat de préjudice grave.
• Changement grave de l'état mental : agitation extrême, confusion, désorganisation, psychose ou manie possible avec altération du jugement ou comportement dangereux, ou incapacité à satisfaire les besoins fondamentaux lorsque cela crée un danger immédiat.
• Urgence médicale ou liée à la consommation de substances : Suspicion de surdosage, intoxication grave, sevrage dangereux, délire ou autre changement soudain nécessitant des soins médicaux urgents.

En cas de danger immédiat, ne laissez pas la personne seule pendant que les secours sont organisés. Suivez les procédures d'urgence locales et composez le 911 en cas de danger immédiat ou d'urgence médicale. Si la personne a des pensées suicidaires, téléphonez ou envoyez un SMS. 9-8-8 : Ligne d’assistance en cas de crise suicidaire avec eux ou les aider à le faire.

En cas de violence, d'abus ou d'exploitation avérés ou soupçonnés, assurez immédiatement la sécurité des personnes concernées et respectez les procédures de sécurité et de signalement applicables.

ACTION : Organisez rapidement une évaluation médicale ou psychiatrique si :

• Pensées suicidaires ou d'automutilation : Des pensées sans danger immédiat.
• Symptômes ou effets importants : symptômes graves, persistants ou s'aggravant de dépression, d'anxiété, de traumatisme, de psychose ou de manie possible, de troubles alimentaires ou de consommation de substances qui affectent considérablement la vie quotidienne, la prise de décision ou la participation en toute sécurité aux soins.
• Autres motifs d’évaluation : un changement marqué par rapport au comportement ou au fonctionnement habituel ; une inquiétude concernant les effets des médicaments ou des substances ; une présentation qui dépasse les compétences du clinicien ; ou une demande d'aide.

Informer le patient des personnes à contacter, du délai de contact et de la marche à suivre en cas d'aggravation de son état. S'assurer que le patient a bien pris contact avec le service lorsque cela est cliniquement nécessaire.

ACTION : Adapter et coordonner les soins musculosquelettiques :

• Soins en toute sécurité : Les soins peuvent se poursuivre lorsqu'ils sont sécuritaires et acceptables et ne retardent pas l'évaluation nécessaire. Adaptez la communication, l'examen et les soins ; obtenir un consentement continu ; et coordonnez-vous avec les autres professionnels de la santé avec la permission du patient.
• Poursuivre l'évaluation musculosquelettique : Ne présumez pas qu'un problème de santé mentale ou de toxicomanie explique les symptômes musculo-squelettiques. Continuez à considérer les causes physiques et à tenir compte du récit du patient.
• Questionnaires: Ils peuvent soutenir la discussion et le suivi, mais ne permettent pas d’établir un diagnostic et ne remplacent ni les questions directes, ni le jugement clinique, ni les mesures à prendre.
• Soutien acceptable : Demandez à la personne quel type d’aide lui convient et si le soutien linguistique, culturel, familial, communautaire ou autre est important pour elle.

ACTION : Documentation et suivi :

Consignez la préoccupation, les questions pertinentes et les réponses de la personne, la décision relative à la sécurité et les raisons qui la justifient, les mesures prises, les conseils donnés et les références effectuées, les communications et le consentement, le suivi prévu ainsi que toute préoccupation non résolue. Respectez les exigences applicables en matière de confidentialité, de sécurité et de signalement.

Pour obtenir des renseignements sur les services provinciaux, territoriaux et nationaux, consultez : Soutien en santé mentale : obtenir de l’aide (Agence de la santé publique du Canada, 2026).

Les signaux d’alerte psychosociaux (drapeaux jaunes) sont des facteurs personnels, sociaux, professionnels, scolaires, liés aux soins de santé, environnementaux ou structurels qui peuvent influencer les symptômes, le fonctionnement, la participation aux activités ou la réponse aux soins. Ils sont liés au contexte et ne constituent ni des diagnostics ni des prédictions certaines. Ils ne signifient pas que les symptômes sont d’origine psychologique. Ils permettent d’adapter la prise en charge et ne nécessitent pas, à eux seuls, une orientation urgente vers un autre professionnel de la santé. Explorez ces facteurs par la discussion et le suivi continu des résultats, en tenant compte des priorités, des forces et de la situation de la personne. Il n’est pas nécessaire d’utiliser un score distinct pour les signaux d’alerte psychosociaux (drapeaux jaunes). Les nouveaux signes ou l’aggravation de signes d’une maladie physique grave doivent être traités selon la procédure relative aux signes d’alerte (drapeaux rouges). Les préoccupations liées à la santé mentale ou à la consommation de substances qui nécessitent une évaluation distincte, ainsi que toute préoccupation immédiate concernant la sécurité, doivent être traitées selon la procédure relative aux signaux d’alerte psychosociaux urgents (drapeaux orange) et aux protocoles d’urgence ou de protection applicables.

Explorez les facteurs pertinents :

• Compréhension, attentes et expériences en matière de soins de santé : Préoccupations liées aux blessures ou aux dommages, incertitude, attentes quant au rétablissement, confiance en ses capacités, conseils contradictoires, expériences antérieures de banalisation des symptômes ou de préjudices subis, et confiance envers les soins reçus.
• Réactions aux symptômes et à l’activité : Inquiétude, peur, évitement, alternance entre périodes d’activité excessive et périodes de repos prolongées, difficulté à gérer le rythme des activités, stratégies d’adaptation, sommeil, confiance en sa capacité à gérer ses symptômes et reprise des activités significatives.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change risk assessment, the working diagnosis, care or referral. Adapt positioning and symptom provocation to the person’s safety, comfort, consent and abilities.

• Consent, positioning and safety: explain expected symptom provocation; check mobility, cervical range, vascular or neurological concerns, recent surgery, pregnancy, frailty and fall risk; use assistance, guarding or an adapted test when needed; stop if the response is unsafe or inconsistent with the intended test.
• General observation and vital signs: appearance, level of alertness, speech, spontaneous eye movements, sitting and standing tolerance, gait safety, heart rate, blood pressure and orthostatic measurements when indicated.
• Neurological and ocular motor screen: cranial nerves, visual fields, pupils and eyelids, gaze-evoked or spontaneous nystagmus, limb strength and sensation, coordination and gait, guided by the presentation.
• Hearing screen: compare hearing when acute vestibular syndrome or new hearing change is reported and coordinate audiology or medical assessment when needed.
• Balance and functional assessment: transfers, stance, gait, turning, head movement during walking and patient-prioritized tasks, with appropriate fall precautions.
• Dix-Hallpike test: use when the history suggests triggered episodic positional vertigo and positioning is safe. Posterior canal BPPV is supported when the manoeuvre provokes vertigo with the expected torsional, upbeating nystagmus. Test both sides when appropriate. (Bhattacharyya et al. 2017); (von Brevern et al. 2015)
• Supine roll test: use when the history is compatible with BPPV and Dix-Hallpike testing shows horizontal or no nystagmus. Canal and side interpretation follows the observed horizontal nystagmus pattern. (Bhattacharyya et al. 2017); (von Brevern et al. 2015)
• Head-Impulse, Nystagmus, Test of Skew (HINTS): this is not a BPPV test. It is limited to clinicians trained to use it in acute vestibular syndrome with spontaneous nystagmus. A central or equivocal result requires emergency stroke evaluation. Do not apply HINTS to brief triggered episodic dizziness or use it as reassurance outside its validated presentation. (Edlow et al. 2023)
• Imaging and vestibular testing: routine imaging or laboratory vestibular testing is not needed when the presentation meets BPPV criteria and no inconsistent signs or symptoms are present. Coordinate medical investigation when findings are atypical, central, auditory, cardiovascular or otherwise likely to change care. (Bhattacharyya et al. 2017); (Edlow et al. 2023)

Repeat and adapt the examination when needed to review response, revisit the working diagnosis or decide whether further assessment or referral is appropriate.

Timing and trigger framework

GRACE-3 developed the following framework for adults with acute dizziness or vertigo of less than two weeks in emergency departments. In this pathway it helps organize risk assessment and referral; it does not diagnose BPPV. (Edlow et al. 2023)

• Triggered episodic vestibular syndrome: brief episodes clearly triggered by movement, including the typical symptom pattern for BPPV when positional testing is concordant.
• Acute vestibular syndrome: acute-onset persistent continuous dizziness or vertigo lasting longer than 24 hours, often with nausea, nystagmus, head-motion intolerance or gait unsteadiness. This is not typical BPPV and requires assessment for central and peripheral causes.
• Spontaneous episodic vestibular syndrome: episodes without a clear trigger. The differential includes transient ischemic attack, vestibular migraine, Meniere disease, cardiac causes and other conditions; BPPV should not be assumed without a compatible positional pattern.

Working clinical presentations

Working presentations may overlap or change. Use the observed timing, triggers and nystagmus pattern rather than symptoms alone, and revisit the impression when findings or response differ from expectations.

• VPPB du canal postérieur : brief position-triggered vertigo with characteristic torsional, upbeating nystagmus during Dix-Hallpike testing. (Bhattacharyya et al. 2017); (von Brevern et al. 2015)
• VPPB du canal horizontal : compatible positional symptoms with horizontal geotropic or apogeotropic nystagmus during supine roll testing. (Bhattacharyya et al. 2017); (von Brevern et al. 2015)
• Recurrent or residual BPPV presentation: a previously confirmed positional pattern returns, or imbalance and motion sensitivity remain after positional vertigo resolves. Recheck for unresolved or another-canal BPPV and for other contributors before assuming recurrence.
• Medically established peripheral vestibular hypofunction: dizziness, visual blurring with head movement, imbalance or falls with a confirmed unilateral or bilateral peripheral vestibular deficit and no untreated BPPV or central cause.
• Atypical, mixed or uncertain presentation: the history and examination do not form a consistent canal-specific pattern, or auditory, neurological, cardiovascular, migraine, medication or multisensory factors may better explain the symptoms. Follow Red Flags and arrange referral or shared care.

Base care on the confirmed presentation, safety, goals, context and response. Develop the plan with the patient and use adaptable principles and options rather than a ranked sequence.

Éducation, autogestion et participation aux activités

• Explain the working diagnosis, the reason for positional testing, expected temporary symptom provocation, fall precautions, the possibility of recurrence and when a changed pattern needs reassessment. (Bhattacharyya et al. 2017)
• Options include gradual return to usual head movement, mobility, daily activity, work and recreation as safety allows. Routine prolonged postural restrictions after a repositioning procedure are unnecessary for typical posterior canal BPPV. (Bhattacharyya et al. 2017)
• Address immediate fall risks, safe transfers, mobility aids, home hazards, driving or work tasks and access to support without promoting unnecessary long-term movement avoidance.

Canalith repositioning and symptom-relieving care

• VPPB du canal postérieur : options include an Epley or another canal-matched repositioning procedure delivered by a clinician with relevant competence. The choice reflects the observed side and nystagmus, mobility, cervical tolerance, preferences and response. (Bhattacharyya et al. 2017); (Thakur et al. 2024)
• VPPB du canal horizontal : a side- and variant-matched repositioning procedure can form part of care when the supine roll pattern is clear and the clinician has relevant competence. Otherwise, referral to a vestibular clinician is appropriate. (Bhattacharyya et al. 2017)
• Recheck symptoms and positional nystagmus after an appropriate interval. Repeat or adapt the manoeuvre when findings remain concordant; revisit the diagnosis when the response is absent, atypical or short-lived.

Physical activity and vestibular rehabilitation

• For resolved BPPV without ongoing imbalance, usual activity and progressive confidence with movement may be sufficient.
• For residual imbalance, motion sensitivity, reduced balance confidence or medically established peripheral vestibular hypofunction, individualized options include gaze-stability, habituation, balance, gait and functional exercises matched to the impairment and goals. Vestibular rehabilitation does not replace a canalith repositioning procedure for confirmed BPPV. (Hall et al. 2022)

Psychological, social, and interdisciplinary support

• Use psychologically informed communication and graded participation when fear of falling, distress or movement avoidance persists. Refer to the separate Orange Flags and Yellow Flags modules when relevant.
• Options include coordinated care with primary care, audiology, otolaryngology, neurology, vestibular rehabilitation, falls services, occupational therapy, mental health, workplace or community supports when needs extend beyond the treating clinician’s scope.
• Where relevant, include culturally grounded, traditional or community-based approaches identified by the patient when they are safe and compatible with the care plan.

Médicament

• Review medication that may contribute to dizziness, sedation, orthostatic symptoms or falls and coordinate any change with the responsible medical clinician. Routine vestibular suppressant medication is not part of usual BPPV care; short-term symptom management for another diagnosed condition remains a medical decision. (Bhattacharyya et al. 2017)

Suivi et réévaluation

• Outcome reassessment: reassess within 1 month after initial observation or treatment to document resolution or persistence of symptoms. Arrange earlier reassessment when symptoms worsen, the pattern changes or a new safety concern emerges (Bhattacharyya et al. 2017).
• Repeat the small outcome set recorded at baseline and review episode pattern, positional findings when relevant, falls, gait and balance, functioning, participation, benefits, harms, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit the clinical presentation, differential diagnosis, referral or shared care when symptoms persist, recur, change or new safety concerns emerge.

• Évolution attendue : confirmed BPPV often improves after one or more appropriately matched repositioning procedures, and spontaneous resolution can occur. Residual imbalance or recurrence is possible, so prognosis is individual and revisable rather than a fixed promise. (Bhattacharyya et al. 2017)
  
• Facteurs associés à une évolution moins favorable : head-trauma-associated BPPV, coexisting vestibular or neurological conditions, impaired mobility or balance, increased fall risk, more than one involved canal, an uncertain diagnosis or barriers to correctly matched repositioning may be associated with more complex care or a variable first-procedure response. These group-level associations do not determine an individual’s outcome. (Alolayet and Murdin 2025); (Bhattacharyya et al. 2017)
  
• Facteurs pouvant favoriser le rétablissement : a clear explanation, correct identification of the presentation, safe canal-matched treatment, early review of persistent or changed symptoms, gradual return to meaningful activity, fall prevention and timely access to vestibular or medical expertise may support recovery without guaranteeing it.
  
• Discussion du pronostic : acknowledge the possibility of recurrence without creating fear, explain how to recognize a familiar positional pattern versus a new red-flag pattern, connect prognosis to the person’s goals and update it using repeated outcomes and response over time.