Understanding BPPV Dizziness: Canalithiasis vs. Cupulolithiasis

Dizziness is one of the most common reasons people seek medical or physiotherapy help.

Often, the cause lies in the inner ear — specifically a condition called Benign Paroxysmal Positional Vertigo (BPPV).

Within BPPV dizziness, there are two subtypes: canalithiasis and cupulolithiasis. Both involve tiny calcium crystals (otoconia) moving where they shouldn’t, but they behave differently and require slightly different treatments.

What is Canalithiasis?

Canalithiasis is the most common form of BPPV. Here’s what happens:

• The inner ear has fluid-filled canals that detect head movement.
• Tiny calcium crystals (otoconia) normally sit in a different part of the inner ear.
• In canalithiasis, these crystals become loose and float freely inside one of the canals.
• When you move your head, the crystals shift, sending false signals to the brain.

Symptoms:

• Sudden spinning dizziness that lasts less than a minute
• Triggered by specific head movements (rolling in bed, looking up/down)
• Often very intense but short-lived

Treatment for Canalithiasis

The good news is canalithiasis responds very well to canalith repositioning maneuvers, such as the Epley maneuver (posterior canal) or the Barbecue roll (horizontal canal).

• These maneuvers use gravity to move the crystals out of the canal and back to their proper place.
• Relief is often immediate or achieved within 1–2 sessions.

What is Cupulolithiasis?

Cupulolithiasis is less common but more stubborn than canalithiasis. Here’s what’s different:

• Instead of floating freely, the crystals stick to the sensory organ (the cupula) inside the canal.
• Because the crystals are “stuck,” the cupula becomes heavier than normal.
• This causes a longer-lasting dizziness signal whenever the head is held in certain positions.

Symptoms:

• Dizziness that lasts longer than a minute while the head is in a triggering position
• Can feel more persistent and harder to shake off
• Same triggers as canalithiasis (rolling in bed, tilting the head) but more prolonged

Treatment for Cupulolithiasis

Because the crystals are attached rather than free-floating, treatment is a little different:

• Liberatory maneuvers (like the Semont maneuver) are used to “dislodge” the crystals from the cupula.
• Once freed, crystals may convert into canalithiasis, at which point repositioning maneuvers (like Epley) are used.
• Vestibular rehabilitation exercises may also be prescribed to help the brain recalibrate.

Canal vs Cupula: Key Differences

Why Physiotherapy is the Best Place to Start

Physiotherapists trained in vestibular rehabilitation can:

• Diagnose the difference between canalithiasis and cupulolithiasis
• Apply the correct maneuver for your condition
• Prescribe balance and vestibular exercises to restore stability
• Provide education to reduce recurrence and manage symptoms at home

Final Word

Not all dizziness is the same — and even within BPPV, the difference between canalithiasis and cupulolithiasis changes the approach to treatment.

With the right assessment, physiotherapy can provide targeted, effective relief so you can get back to moving with confidence.

👉 If you’re experiencing dizziness, book an assessment today — the right treatment could make the difference in just one session.