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BPPV as a Cause of Vertigo in Multiple Sclerosis

or Why Is This Good News?


Updated July 02, 2014

About 20% of people with multiple sclerosis (MS) experience vertigo at some point in their lives, as compared to about 10% of the general population. When someone with MS complains to their neurologist that they are experiencing the symptoms of vertigo, it is likely that many docs will assume that it is caused by a lesion on a cranial nerve (CN VIII) in the cerebellum, since lesions and inflammation are the primary causes of most MS symptoms. This may result in a trip to the MRI or a prescription for a variety of drugs to control the symptoms (or even a course of corticosteroids to bring down the presumed inflammation).

Hold on a minute.

Research indicates that up to 60% of the vertigo in people with MS is actually something called benign paroxysmal positional vertigo (BPPV), rather than due to a demyelinating lesion. Why is this important (and exciting)? This is great news, because BPPV can often be treated without medications. It also does not indicate a relapse or increased disease activity. Hooray. Read on.

What Does It Feel Like?

BPPV feels like severe vertigo that occurs upon movement of the head, especially when rolling over in bed, getting out of bed or tipping the head back to look up. It feels like you (or your surroundings) are spinning or tilting when you are not. It usually lasts just a couple of minutes.

What Causes It?

BPPV is caused by debris that has collected in a specific part (semicircular canals) of the inner ear, which is part of the vestibular system. The debris, called otoconia or canaliths, are actually small calcium carbonate crystals that we all have. They are usually attached to the tiny hairs in your inner ear that detect movement, but can become dislodged and float around. When a person with BPPV moves his or her head, these crystals shift and stimulate these tiny hairs, sending false signals to the brain. The vertigo happens because of the confusion caused by these signals and other systems controlling proprioception. Since many people with MS already have difficulty with proprioception, this may make them feel BPPV even more acutely.

How Severe Can It Get?

It is usually pretty mild, but can be severe enough to cause vomiting. It can also interfere with balance to the extent that it is difficult to stand or walk. BPPV typically goes away in a couple of weeks, but can recur intermittently.

Additional Points/Information

Suspect BPPV First: I’ll say it again –- make sure that you are evaluated for BPPV if you have vertigo and MS. There are many things that can be done to treat BPPV that do NOT require medication, which usually consist of painless maneuvers done in the doctor’s office or exercises to do at home to move the crystals to another part of the ear.

Otolaryngologist: This is a fancy name for an ear, nose and throat specialist (ENT). Ideally, you would see one of these for your evaluation (and treatment) for BPPV. Really ideally, if you live in a place with access to such a specialist, you would be seen by an otoneurologist or a neurotologist (specialists in both matters of the inner ear and neurology) for any cases of MS-related vertigo.

Careful With The Meds: If you have BPPV (or other MS-related vertigo) that is severe or causing vomiting, you may be prescribed medications to help you feel better until other treatments can start working and symptoms remit. These drugs include: the scopolamine patch (Transderm-Scop); antihistamines (like Dramamine or Benadryl) or even a sedative like Valium. All of these drugs can make you drowsy, which can greatly contribute to the fatigue many people with MS experience. They can also make you feel disoriented and cause problems with balance, so exercise extreme caution when taking them, especially if you already are unsteady on your feet.


Frohman EM, Kramer PD, Dewey RB, Kramer L, Frohman TC. Benign paroxysmal positioning vertigo in multiple sclerosis: diagnosis, pathophysiology and therapeutic techniques. Multiple Sclerosis. 2003 Jun;9(3):250-5.

Frohman EM, Zhang H, Dewey RB, Hawker KS, Racke MK, Frohman TC. Vertigo in MS: utility of positional and particle repositioning maneuvers. Neurology. 2000 Nov 28;55(10):1566-9.

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