Blog For Therapists & Other Providers Who Treat Dizziness & Vertigo

Atypical BPPV: Understanding Posterior Canal BPPV Variants

May 13, 2026

Most clinicians are comfortable treating classic posterior canal BPPV.

A patient rolls over in bed, looks up, bends forward, or gets out of bed and experiences brief vertigo. You perform the Dix-Hallpike test, see the expected upbeat torsional nystagmus toward the affected ear, complete a Modified Epley or Semont maneuver, and symptoms improve quickly.

Simple.

Except when it is not.

What happens when the history sounds exactly like BPPV, but the Dix-Hallpike is negative?

What if symptoms are stronger when the patient sits up than when they lie back?

What if the nystagmus is downbeat instead of upbeat?

What if the nystagmus is sustained or the standard maneuvers fail?

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Atypical BPPV: Understanding Posterior Canal BPPV Variants

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Two Step