What is the first line treatment for positional vertigo?

From the Guidelines

The first line treatment for positional vertigo is the Epley maneuver, also known as the canalith repositioning procedure (CRP), which has been shown to be highly effective in resolving symptoms of Benign Paroxysmal Positional Vertigo (BPPV) 1.

Key Points to Consider

• The Epley maneuver is a series of head movements designed to reposition displaced calcium crystals in the inner ear, and it has a success rate of 80-90% after 1-3 treatments 1.
• The procedure involves a series of specific head position changes, designed to utilize gravity to move free-floating particles through the alignment of the posterior semicircular canal back into the vestibule, thereby relieving the pathologic stimulus that had been producing the vertigo in BPPV 1.
• A 2010 meta-analysis of CRP found that patients treated with CRP had a 6.5-times greater chance of improvement in clinical symptoms relative to controls, and a similar likelihood of negative Dix-Hallpike maneuver 1.
• The 2014 updated Cochrane review included 11 trials and reported that CRP is more effective when compared with sham maneuvers or controls, with complete resolution of vertigo occurring significantly more often in the CRP treatment group 1.

Recommendations for Treatment

• Clinicians should treat patients with posterior canal BPPV with a canalith repositioning procedure, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.
• Patients should be informed that nausea, occasional vomiting, and/or a sense of falling may arise during the CRP, and antiemetic prophylaxis may be offered 30 to 60 minutes prior to CRP if necessary 1.
• Postprocedural postural restrictions are not recommended after canalith repositioning procedure for posterior canal BPPV, as they have not been shown to improve outcomes 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. Recommended dosage: 25 mg to 100 mg daily, in divided doses.

The first line treatment for positional vertigo is meclizine with a recommended dosage of 25 mg to 100 mg daily, in divided doses 2.

• Key points:
  • Meclizine is indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults.
  • The recommended dosage is 25 mg to 100 mg daily, in divided doses.
• Important consideration: May cause drowsiness, use caution when driving a car or operating dangerous machinery 2.

From the Research

Treatment for Positional Vertigo

• The first line treatment for positional vertigo, specifically benign paroxysmal positional vertigo (BPPV), is the canalith repositioning maneuver (CRM), such as the Epley or Semont maneuver 3.
• The Epley maneuver is a bedside positional maneuver that can be used to treat posterior canal BPPV, and its application can reduce resource utilization, ED length of stay, and use of ineffective medications 4.
• Studies have shown that the Epley maneuver is more effective than other treatments, such as the Brandt-Daroff maneuver, in treating posterior canal BPPV 5, 6.
• The modified Epley maneuver has been found to be more effective for self-treatment of posterior canal BPPV than modified Semont maneuver and Brandt-Daroff maneuver 6.
• For apogeotropic benign positional vertigo, the head-shaking maneuver has been found to be more effective than the modified Semont maneuver 7.

Treatment Approach

• The treatment approach for BPPV typically involves a bedside test, such as the Dix-Hallpike test, followed by a bedside positional maneuver, such as the Epley maneuver 4.
• Postural restrictions are not necessary after CRM treatment 3.
• Medications, such as meclizine, are not recommended as a first-line treatment for BPPV, as they have been found to be ineffective and have side effects 4.

Efficacy of Treatments

• The efficacy of the Epley maneuver has been found to be higher than that of the Semont maneuver and Brandt-Daroff maneuver in treating posterior canal BPPV 5, 6.
• The head-shaking maneuver has been found to be more effective than the modified Semont maneuver in treating apogeotropic HC-BPV 7.
• The frequency of side effects has been found to be not significantly different among the three physical therapy groups 6.