Differentiating Atypical BPPV from Central Positional Vertigo: A Narrative Review

While typical benign paroxysmal positional vertigo (BPPV) presents with reproducible patterns of nystagmus and vertigo during positional testing, atypical variants often deviate from typical patterns, making diagnosis more complex. Recognizing atypical BPPV is crucial to avoid misdiagnosis and inappropriate management. This study aims to describe the clinical spectrum of atypical BPPV, differentiate it from central positional vertigo, and provide practical diagnostic guidance for clinicians. A narrative review was conducted to explore the clinical spectrum of atypical BPPV. Findings indicate that it may present with vertigo without nystagmus, conflicting torsional components in bilateral cases, or persistent symptoms despite repositioning maneuvers. Canal switch and pseudo-spontaneous nystagmus have also been described. Although these variants may mimic central etiologies, the absence of consistent neurological signs supports a peripheral mechanism. Diagnosis relies on detailed assessment of nystagmus characteristics-such as latency, /duration, and direction-as well as the exclusion of red flags, like direction-changing nystagmus without head movement, vomiting, or non-positional ocular motor abnormalities. Atypical BPPV remains a diagnostic challenge and requires careful bedside assessment and clinical testing. Understanding these variants is essential for timely and appropriate treatment. When doubt persists and resolution with treatment does not occur, neuroimaging should be considered to exclude central pathology.