What is the management for Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

Management for benign paroxysmal positional vertigo (BPPV) primarily involves repositioning maneuvers, such as the Epley maneuver, to move displaced calcium crystals back to their proper location in the inner ear, as recommended by the strongest and most recent evidence 1.

Key Considerations

• The Epley maneuver should be performed by a healthcare provider initially but can be taught to patients for home use, taking about 15 minutes to complete.
• For posterior canal BPPV, the Semont maneuver or Brandt-Daroff exercises may also be effective alternatives.
• Medications, such as vestibular suppressants like meclizine, play a limited role in BPPV management and should be used sparingly to avoid delaying central compensation.

Diagnosis and Assessment

• Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, as stated in the guideline 1.
• Patients should be assessed for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling, as recommended by the guideline 1.

Treatment and Follow-up

• Clinicians should treat patients with posterior canal BPPV with a canalith repositioning procedure, as strongly recommended by the guideline 1.
• Patients should be advised to avoid sudden head movements, sleeping with extra pillows to keep the head elevated at night, and getting up slowly from lying positions during the recovery period to minimize symptom provocation.
• Clinicians should reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms, as recommended by the guideline 1.

Education and Counseling

• Patients should be educated regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up, as recommended by the guideline 1.
• Counseling should include assessment of home safety, activity restrictions, and the need for home supervision until BPPV is resolved, particularly in the elderly and frail, as discussed in the guideline 1.

From the Research

Management for BPPV

• The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers 2.
• Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for evidence-based medicine 2.
• The Epley manoeuvre is a safe and effective treatment for posterior canal BPPV, with a significant effect in favour of the Epley manoeuvre over controls 3, 4, 5.
• The Epley manoeuvre has been shown to be more effective than vestibular rehabilitation at 1-week follow-up, but there is inconsistent evidence for its effectiveness at 1-month follow-up 6.
• The choice of maneuver is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient 2.
• Chair-assisted treatment may be of help if available, while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV 2.
• Patients with unsatisfactory outcomes may need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities, or risk factors for recurrences 2.

Treatment Outcomes

• Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham manoeuvre or control 4, 5.
• Conversion of Dix-Hallpike positional test result from positive to negative significantly favoured the Epley treatment group when compared to a sham manoeuvre or control 4, 5.
• Adverse effects were infrequently reported, with no serious adverse effects of treatment 3, 4, 5.