From the Guidelines
Benign paroxysmal positional vertigo (BPPV) is best treated with canalith repositioning procedures, specifically the Epley maneuver, as it has a high success rate of around 80% with only 1-3 treatments, according to the clinical practice guideline: benign paroxysmal positional vertigo (update) 1. The Epley maneuver involves a series of head movements that help relocate displaced calcium crystals from the semicircular canals back to the utricle where they belong.
- For posterior canal BPPV (most common type), the patient should sit upright, turn their head 45 degrees toward the affected side, quickly lie back with their head hanging slightly off the examination table, wait 30 seconds, turn their head 90 degrees to the opposite side, wait another 30 seconds, then roll their body to that side while keeping the head turned, wait 30 seconds, and finally return to a sitting position.
- This procedure should be repeated three times daily until symptoms resolve for 24 hours. Some key points to consider:
- Home-based Brandt-Daroff exercises can also help, involving repeated position changes from sitting to lying on each side.
- Medications like meclizine (25mg every 4-6 hours as needed) or diazepam may provide temporary symptom relief but don't treat the underlying cause, and their use is not routinely recommended for treatment of BPPV, other than for the short-term management of autonomic symptoms, such as nausea or vomiting, in a severely symptomatic patient 1.
- Most patients experience complete resolution within 1-3 treatment sessions.
- BPPV occurs when calcium carbonate crystals become dislodged from the utricle and move into the semicircular canals, causing inappropriate fluid movement and false signals of rotation when the head position changes. It's also important to note that vestibular rehabilitation may be offered in the treatment of BPPV, based on controlled observational studies and a balance of benefit and harm 1.
From the Research
BPPV Treatment Options
- The Epley maneuver is a commonly used treatment for benign paroxysmal positional vertigo (BPPV) and has been shown to be effective in resolving vertigo symptoms and converting a positive Dix-Hallpike test to negative 2, 3.
- Vestibular rehabilitation is another treatment option for BPPV, but studies have shown that the Epley maneuver is more effective at 1-week follow-up 2.
- Alternating the Epley and Semont maneuvers may be more effective than repeating the same maneuver in treating BPPV 4.
- The Semont maneuver is also a effective treatment for post-canal BPPV, with similar success rates to the Epley maneuver 5.
Comparison of Treatment Options
- A study comparing the Epley maneuver to vestibular rehabilitation found that the Epley maneuver was more effective at 1-week follow-up, but there was inconsistent evidence for the effectiveness of the Epley maneuver at 1-month follow-up 2.
- Another study found that the Epley maneuver was more effective than the Brandt-Daroff exercises in treating BPPV 3.
- A comparative study found that both the Epley and Semont maneuvers were effective in treating post-canal BPPV, with similar success rates 5.
Treatment Recommendations
- The Epley maneuver or Semont maneuver should be the first-line treatment for BPPV in the elderly 6.
- Following the Epley maneuver with self-treatment at home using a modified Epley procedure may improve outcomes 6.
- Postural restrictions are not necessary after canalith repositioning maneuver (CRM) treatment 6.
- Medications do not work as well as CRM, but studies comparing treatments are limited 6.