Revised criteria for suspicion of non-benign positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most commonly diagnosed vestibular vertigo. BPPV can be diagnosed by clinical examination and its treatment is based on particle repositioning manoeuvres, and specialized equipment is not required. Therefore, most patients could be diagnosed and treated by their general practitioner. Unfortunately, not all positional vertigos are benign. Symptoms similar to those of BPPV can be caused by diseases that affect the central nervous system. It must be possible to define criteria that allow us to suspect, in a patient with symptoms of positional vertigo, the possibility of a cerebral origin ('non-benign PV'). Requests for magnetic resonance imaging must be justified by the fulfillment of these criteria. That is especially relevant in primary care, because these criteria should make possible to distinguish between patients with positional vertigo that could be treated by general practitioner and patients that need to be directed to especialized units. We propose the following revised criteria for suspected non-benign PV: (i) association with signs or symptoms of neurological disorder, (ii) nystagmus without dizziness in positional diagnostic tests, (iii) atypical nystagmus direction, (iv) poor response to therapeutic manoeuvres and (v) recurrence (confirmed by positional tests) on at least three occasions.