From the Guidelines
The first line of treatment for Benign Paroxysmal Positional Vertigo (BPPV) should be a canalith repositioning procedure, such as the Epley maneuver for posterior canal BPPV, as it has a strong recommendation based on systematic reviews of RCTs and a preponderance of benefit over harm 1. This procedure involves a series of head position changes that help move the displaced calcium carbonate crystals (otoconia) from the semicircular canals back to the utricle where they belong.
- The Epley maneuver typically takes about 5-10 minutes to perform and can be done by a healthcare provider or taught to patients for home treatment.
- For horizontal canal BPPV, the BBQ roll or Lempert maneuver may be used instead.
- These repositioning maneuvers are effective in about 80% of cases after a single treatment session, with success rates increasing to over 90% with repeated treatments. Medications are generally not recommended as first-line therapy for BPPV as they don't address the underlying mechanical problem and may delay recovery by suppressing the central adaptation process. The effectiveness of these maneuvers is based on the understanding that BPPV results from displaced otoconia that inappropriately stimulate the semicircular canals during head movement, causing brief episodes of vertigo. By repositioning these particles, the abnormal stimulation is eliminated, resolving symptoms. Vestibular rehabilitation may also be offered as an option in the treatment of BPPV, based on controlled observational studies and a balance of benefit and harm 1.
From the Research
Treatment of BPPV
The first line of treatment for a patient diagnosed with Benign Paroxysmal Positional Vertigo (BPPV) is the canalith repositioning procedure (CRP) or repositioning maneuvers.
- The Epley maneuver, Semont maneuver, and Gufoni maneuver are examples of CRP used to treat BPPV, with the choice of treatment depending on the canal involved and clinician preference 2, 3.
- These maneuvers have been shown to be highly effective in treating BPPV, with success rates ranging from 85% to 90% 2, 4, 5.
- The treatment is generally non-invasive and can be performed in a clinical setting without the need for pre-medication or specialized equipment.
Efficacy of CRP
Studies have demonstrated the efficacy of CRP in treating BPPV, including:
- A study of 19 patients treated with a modified Epley maneuver, which showed an efficacy rate of 89.5% 2.
- A study of 965 patients treated with CRP, which showed that symptoms subsided immediately in 85% of patients, with a mean follow-up of 74 months 4.
- A study of 30 patients treated with the Epley maneuver, which showed a success rate of 87% 5.
Prognostic Factors
Prognostic factors that may affect the outcome of CRP treatment for BPPV include:
- Age, with older patients having a higher recurrence rate 4, 6.
- Involvement of two canals or bilateral disease, which can affect initial treatment outcome and increase recurrences 6.
- Secondary BPPV, abnormal electronystagmographic findings, and improper performance of maneuvers, which can affect initial and repeat treatment outcomes 6.