Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 7 Sept 2026Clinical review pending
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Atypical positional symptoms need reassessment
Continuous vertigo, new neurological deficits or severe imbalance between attacks is not adequately explained by uncomplicated posterior-canal BPPV.
Action: Stop routine manoeuvres and arrange urgent neurological or stroke assessment when acute central features are present; sudden hearing loss also needs an urgent hearing-loss pathway.
Synopsis
Recognise a canal-specific positional syndrome, select safe diagnostic and repositioning manoeuvres, and reassess persistent or atypical symptoms without assuming every positional complaint is benign.
BPPV causes short attacks initiated by changes in head position.
The posterior semicircular canal is most commonly affected.
Hallpike testing should reproduce the appropriate positional nystagmus pattern.
Key red flags
Persistent vertical or otherwise atypical positional nystagmus, new diplopia or inability to sit or walk safely should prompt assessment for central disease.
Investigation priorities
01
Trained Hallpike examinationFirst step
Confirm a posterior-canal pattern while assessing the symptomatic side.
Management branches
ConfirmedPosterior-canal repositioning treatment
A compatible history and positional response identify posterior-canal BPPV.
Check consent, cervical stability and practical ability to transfer safely before a trained clinician performs the manoeuvre.
Use an Epley or other appropriately selected canalith repositioning procedure for the identified side, explaining that transient vertigo and nausea may occur.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.