Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder and is generally responsive to canalith repositioning maneuvers. However, a considerable proportion of patients present with atypical or controversial syndromes in which repositioning is less effective, raising challenges in differential diagnosis and management. Based on more than a decade of clinical practice and observational studies, this review summarizes insights into the diagnostic pitfalls, clinical characteristics, and underlying mechanisms of BPPV and its variants. The incidence of controversial syndromes may reach up to 50% when diagnosis relies solely on positional nystagmus, highlighting the importance of recognizing atypical features such as prolonged nystagmus duration, spontaneous or post-head-shaking nystagmus, and weaker intensity compared with typical BPPV. Proposed mechanisms include light cupula, vestibular migraine, and small vessel disease-related central lesions. Management strategies are discussed, including individualized repositioning maneuvers, vestibular rehabilitation, and pharmacological interventions such as flunarizine, betahistine, and clonazepam in selected cases. Residual dizziness and recurrence remain important clinical issues, with risk factors such as advanced age, female sex, migraine, metabolic disorders, and osteoporosis contributing to recurrence. This review emphasizes the necessity of accurate diagnostic grading, cautious interpretation of positional nystagmus, and comprehensive evaluation of comorbidities to optimize patient outcomes.