What are the current treatment guidelines for Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

The current guidelines for treating benign paroxysmal positional vertigo (BPPV) primarily recommend canalith repositioning procedures as first-line treatment. For posterior canal BPPV, which is most common, the Epley maneuver is recommended, involving a series of head position changes that move displaced calcium crystals from the semicircular canal back to the vestibule, as described in the 2017 clinical practice guideline update 1. The Semont maneuver is an effective alternative. For horizontal canal BPPV, the roll maneuver (Lempert or barbecue maneuver) is recommended. These procedures should be performed by healthcare providers initially, but patients can be taught to perform them at home for recurrent episodes.

The diagnosis of BPPV should be based on a combination of clinical history, physical examination, and diagnostic tests such as the Dix-Hallpike maneuver, as outlined in the guideline update 1. The primary outcome considered in this guideline is the resolution of symptoms associated with BPPV, with secondary outcomes including an increased rate of accurate diagnoses, a more efficient return to regular activities, and a reduction in recurrence of BPPV.

Medication is generally not recommended for BPPV as it doesn't address the underlying mechanical problem and may delay effective treatment, as stated in the guideline update 1. Vestibular suppressants like meclizine (25mg every 4-6 hours as needed) may temporarily relieve symptoms but should be used sparingly and short-term only. Patients should be reassessed after treatment, with repositioning maneuvers repeated if symptoms persist. Most cases resolve with 1-3 treatments.

For rare refractory cases that significantly impact quality of life, surgical options like posterior semicircular canal occlusion may be considered, as discussed in the guideline update 1. BPPV occurs when calcium carbonate crystals (otoconia) become dislodged from the utricle and move into the semicircular canals, causing inappropriate fluid movement and false sensation of motion with position changes. The canalith repositioning maneuver (Epley maneuver) is a effective treatment for posterior semicircular canal BPPV, with a success rate of 90% to 98% when additional repositioning maneuvers are subsequently performed, as reported in the guideline update 1.

Some key points to consider in the treatment of BPPV include:

• The use of canalith repositioning procedures as first-line treatment
• The importance of accurate diagnosis and differentiation from other causes of vertigo and dizziness
• The role of patient education and self-treatment in the management of recurrent episodes
• The limited use of medication in the treatment of BPPV
• The consideration of surgical options for refractory cases.

Overall, the treatment of BPPV should be guided by the current clinical practice guidelines, which emphasize the use of canalith repositioning procedures and patient education, and minimize the use of medication and surgical interventions.

From the Research

Current Guidelines for Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

The current guidelines for the treatment of BPPV involve the use of canalith repositioning maneuvers, such as the Epley, Semont, and Gufoni's maneuvers, which are considered level 1 evidence treatment for evidence-based medicine 2.

Treatment Options

• The choice of maneuver depends on the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient 2.
• The Epley maneuver is a commonly used treatment for posterior canal BPPV, with a high success rate in resolving vertigo symptoms 3.
• Other particle repositioning maneuvers, such as the Semont and Gans maneuvers, have also been shown to be effective in treating BPPV 3.
• Postural restrictions after the Epley maneuver may improve treatment efficacy, although the benefit is small 4.

Assessment and Treatment

• Repeated testing and treatment of BPPV within the same session is a safe and effective approach to management, with a low risk of canal conversion 5.
• Vertigo and nystagmus throughout the Epley maneuver are not indicative of treatment success 5.
• Clinicians should be mindful of the possibility of post-treatment otolithic crisis following the treatment of BPPV 5.

Special Considerations

• Patients with anterior canal and apogeotropic posterior canal BPPV may require different treatment approaches, although the evidence for these variants is weaker 2.
• Surgical canal plugging may be indicated in selected cases of intractable severe BPPV 2.
• Patients with recurrences or unsatisfactory outcomes may require further investigation to identify underlying causes, such as multiple canal involvement or associated comorbidities 2.