Vestibular Neuritis vs. BPPV: Two Types of Vertigo, Totally Different Fixes

The Quick Test: Which One Is This?

Answer these two questions:

Question 1: How long does each episode last?

Seconds to one minute → Probably BPPV

• The spinning starts, peaks, then fades within about 30-60 seconds
• Then you feel okay until you move again

Hours to days, non-stop → Probably Vestibular Neuritis

• The spinning is CONSTANT
• It doesn’t stop even when you hold perfectly still
• The severe phase lasts 1-3 days

Question 2: Does position trigger it?

Yes — specific movements set it off → Probably BPPV

• Rolling over in bed
• Looking up at a shelf
• Bending down to tie shoes
• Lying down at night

No — it’s just always there → Probably Vestibular Neuritis

• Movement makes it worse, but it never fully stops
• Even lying still, the room is spinning

The Cheat Sheet

	BPPV	Vestibular Neuritis
Duration	10-60 seconds	Days (constant)
Trigger	Head position	Nothing — always there
Between episodes	Totally fine	Never fully stops
Hearing	Normal	Normal
Fix	15-minute maneuver	Weeks of brain adaptation

BPPV: The Crystal Problem

What’s Actually Happening

Inside your ear, tiny calcium crystals (smaller than grains of sand) normally sit in a structure called the utricle, where they help you sense gravity.

Sometimes these crystals break loose and roll into the semicircular canals — the curved tubes that detect rotation. They’re not supposed to be there.

Now when you move your head, these crystals tumble through the fluid like rocks in a pipe, sending your brain a false “WE’RE SPINNING!” signal. When the crystals settle (after 30-60 seconds), the signal stops. That’s why each episode is brief.

Think of it like this: You know those maze games where you tilt the board to roll a ball through? Your ear has loose balls rolling around, triggering false alarms every time you tilt.

Who Gets This

BPPV is the most common vestibular disorder. Risk factors include:

• Age over 50
• Being female (2-3x more common)
• Head injury
• Prolonged bed rest
• Vitamin D deficiency (emerging research)
• Having had vestibular neuritis (10-15% develop BPPV later)

Often there’s no clear cause — the crystals just… broke loose.

How We Fix It

The Epley Maneuver — Success rate: 70-90% in a single session

This is a specific sequence of head positions that uses gravity to roll the crystals out of the canal and back where they belong. Takes about 15 minutes. Often works immediately.

There are different maneuvers for different canals:

• Epley — for the posterior canal (most common)
• BBQ Roll — for the horizontal canal
• Others — for rarer variants

A vestibular specialist figures out which canal is affected and does the right maneuver.

Can you do it yourself? Partially. Self-Epley is possible, but provider-administered is more effective because they can confirm which ear and canal is affected. Doing the wrong maneuver won’t help.

What DOESN’T Work for BPPV

• Meclizine — Does nothing. It doesn’t move crystals. It just makes you drowsy while your crystals stay stuck. This is one of the most common treatment errors.
• MRI or CT scans — Useless for BPPV. Guidelines specifically recommend against routine imaging.
• Position restrictions after Epley — Old advice said to sleep sitting up. Studies show no benefit. Don’t bother.
• Waiting it out — BPPV can resolve on its own (27-50% do), but why wait weeks when a 15-minute maneuver could fix it today?

Vestibular Neuritis: The Nerve Problem

What’s Actually Happening

Your vestibular nerve — the cable that sends balance signals from your ear to your brain — got inflamed. Usually from a virus, often HSV-1 (the cold sore virus that most adults carry). You might have had a cold 1-2 weeks before.

The inflammation damages the nerve, and suddenly your brain is getting asymmetric signals: one ear says “everything’s fine,” the other ear says nothing (or garbage). Your brain interprets this mismatch as spinning.

Think of it like this: Imagine your brain has two gyroscopes — one in each ear — constantly telling you which way is up. One gyroscope just went offline. Your brain is getting “we’re level” from one side and silence from the other. It takes time for your brain to learn to work with just one gyroscope.

Who Gets This

• Usually follows a viral infection (cold, flu) by 1-2 weeks
• Adults 30-60 most commonly affected
• No clear risk factors — it’s essentially random bad luck

How We Fix It

Steroids (if caught early) — 76% complete recovery vs 27% without

Corticosteroids reduce the inflammation and give your nerve a chance to heal. But timing is everything:

• Within 24 hours = best results
• Within 72 hours = still helpful
• After that = diminishing benefit

Vestibular Rehabilitation — Strong evidence, essential for recovery

Your brain needs to recalibrate to work with one damaged balance sensor. This doesn’t happen automatically — you have to challenge the system. Specific exercises include:

• Gaze stabilization (keeping your eyes fixed while moving your head)
• Balance training
• Controlled exposure to movements that trigger symptoms

Start when severe vertigo allows (usually days 3-7). Continue for 6-12 weeks.

What DOESN’T Work for Vestibular Neuritis

• Epley maneuver — Wrong condition. This is for crystals, not nerve inflammation.
• Antivirals — Despite the virus connection, clinical trials showed zero benefit. Valacyclovir doesn’t help.
• Prolonged meclizine — Helpful for the first 48-72 hours, then actively harmful. It prevents your brain from recalibrating. Stop after 3 days max.
• Bed rest — Feels right, but delays recovery. Your brain needs movement to adapt.

The Treatment Trap: Why Wrong Diagnosis = Wrong Treatment

This is important: the treatments are condition-specific.

If you have BPPV but get treated like VN:

• You take meclizine for weeks (doesn’t move crystals)
• You’re told to “wait it out” (when a 15-minute fix exists)
• You suffer unnecessarily

If you have VN but get treated like BPPV:

• Someone does an Epley maneuver (won’t help)
• You’re told it should be fixed immediately (it won’t be)
• You miss the steroid window

Emergency departments misdiagnose vestibular disorders 74-81% of the time. This isn’t because ER doctors are bad — it’s because these conditions are confusing and time is limited.

If your first treatment didn’t work, question the diagnosis.

Can You Have Both?

Yes, actually.

About 10-15% of people with vestibular neuritis develop BPPV weeks to months later. Here’s why: the inflammation damages the utricle (where crystals live), causing some to break loose and drift into the canals.

How this plays out:

1. You get vestibular neuritis — constant vertigo for days
2. You recover over weeks
3. You’re feeling mostly better
4. Suddenly you have NEW brief positional vertigo when you roll over

That’s secondary BPPV. Different condition, different treatment. The Epley maneuver that wouldn’t have helped your VN will absolutely help this.

If you’re a VN patient who was improving and now has new positional symptoms — tell your doctor. You probably need a Dix-Hallpike test and possibly an Epley.

When to Get Help NOW

The Weird But Important One

If you have acute constant vertigo but a doctor turns your head quickly and your eyes track smoothly (no “catch-up” movement) — that’s actually a red flag.

In vestibular neuritis, the head impulse test is ABNORMAL (your eyes can’t track, they make a catch-up jump). A NORMAL test with acute vertigo suggests the problem might be in the brain, not the ear.

This is counterintuitive: an abnormal test = peripheral (safe). A normal test = central (concerning).

Doctors trained in the HINTS exam know this. It’s more accurate than early MRI for detecting stroke.

Recovery: What to Expect

BPPV Recovery

With treatment: Often same-day resolution. Sometimes needs 2-3 sessions.

Without treatment: Can resolve on its own in weeks to months (27-50% do), but why wait?

Recurrence: Common — 22-29% within a year, up to 50% over 5 years. But each episode is treatable, and many people learn to self-treat.

Vestibular Neuritis Recovery

Recurrence: Uncommon — only 2-11% have another episode. If vertigo keeps coming back, it’s probably a different condition (vestibular migraine, Ménière’s).

Important Statistics

Still Not Better? Troubleshooting

For BPPV:

“The Epley didn’t work”

• Was it definitely the right canal? There are different maneuvers for different canals.
• Was it actually BPPV? If vertigo is constant, not positional, that’s not BPPV.
• Try again — success increases with repetition.

“It keeps coming back”

• BPPV has high recurrence. Some people get it multiple times a year.
• Consider vitamin D supplementation (emerging evidence suggests it helps)
• Learn self-treatment so you can fix it quickly when it recurs

For Vestibular Neuritis:

“I’m still dizzy after a month”

• Are you still taking meclizine? Stop — it’s blocking compensation.
• Are you doing vestibular rehab consistently? This is essential, not optional.
• Is anxiety taking over? Psychological factors predict outcome more than test results do.

“I’m having new brief positional episodes”

• That’s probably secondary BPPV (10-15% of VN patients get this)
• Different condition, different treatment
• Get tested with Dix-Hallpike

Who Can Help

The Bottom Line

Both BPPV and vestibular neuritis make the world spin. But that’s where the similarity ends.

BPPV = loose crystals = brief positional episodes = fixable with a head maneuver = 70-90% cure rate in one session

Vestibular Neuritis = inflamed nerve = constant vertigo for days = brain adapts over weeks = most people recover fully

The treatments are completely different. Getting the right diagnosis matters.

If you’re still suffering, question whether you have the right diagnosis. If meclizine isn’t helping, that’s not surprising — it doesn’t fix either condition. Find a vestibular specialist who can actually diagnose and treat the root cause.

You’re not crazy. Your inner ear is genuinely malfunctioning. And for both of these conditions, there’s a path forward.