Dizziness (BPPV)

• 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).
  
• Sociodemographic information: age, sex, gender identity, language, occupation, caregiving responsibilities and factors that affect balance, mobility, access or communication.

Primary concerns

• 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.
• Functioning and participation: falls or near-falls, gait and transfer safety, mobility aids, driving, work, school, caregiving, sleep, physical activity, movement avoidance and confidence.
• Body systems review: neurological, cardiovascular, vestibular and auditory, visual, musculoskeletal, endocrine and metabolic, and other systems suggested by the presentation.
• Health, lifestyle and history: 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.
• Medication review: 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.
• Social determinants of health: 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.
• Patient perspective: understanding of the symptoms, priorities, preferences, cultural context, concerns, expectations, acceptable symptom provocation and previous care experiences.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

Outcome measures

• Use measures that are meaningful to the patient and practical to repeat. Record a baseline and reassess often enough to guide decisions.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: 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.
• Individual goals: agree on patient-defined goals and how progress will be recognized. SMART wording may be used.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• 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.

• Posterior canal BPPV: brief position-triggered vertigo with characteristic torsional, upbeating nystagmus during Dix-Hallpike testing. (Bhattacharyya et al. 2017); (von Brevern et al. 2015)
• Horizontal canal BPPV: 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.

Education, self-management and participation

• 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

• Posterior canal BPPV: 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)
• Horizontal canal BPPV: 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.

Medication

• 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)

Monitoring and reassessment

• 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.

• Expected course: 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)
  
• Factors associated with a less favourable course: 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)
  
• Potential supports for recovery: 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.
  
• Discussing prognosis: 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.