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

From the Guidelines

The primary treatment for Benign Paroxysmal Positional Vertigo (BPPV) is canalith repositioning procedures, with the Epley maneuver being the most commonly used for posterior canal BPPV, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1. This procedure involves a series of head position changes that help move displaced calcium crystals from the semicircular canals back to the utricle where they belong. For horizontal canal BPPV, the Lempert (BBQ) roll or Gufoni maneuver may be used instead. These maneuvers should be performed by a healthcare provider initially, but patients can be taught to perform them at home for recurrent episodes. Some key points to consider in the treatment of BPPV include:

• The use of canalith repositioning procedures as initial therapy for patients with posterior canal BPPV, as strongly recommended by the guidelines 1.
• The option to offer observation with follow-up as initial management for patients with BPPV, as stated in the guidelines 1.
• The recommendation against routine treatment of BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines, as stated in the guidelines 1.
• The importance of educating patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up, as recommended by the guidelines 1. Vestibular rehabilitation exercises may be recommended for residual symptoms. Medication therapy is generally limited and not a first-line treatment, though antivertigo medications like meclizine (25mg every 4-6 hours as needed) or diazepam (2-5mg every 8 hours as needed) may be prescribed for short-term symptom management during severe episodes. These medications should be used sparingly as they can delay central compensation. BPPV typically resolves within weeks with proper treatment, though recurrence rates are 15-50%. The effectiveness of repositioning maneuvers is based on the understanding that BPPV results from otoconia (calcium carbonate crystals) that have dislodged from the utricle and moved into the semicircular canals, causing inappropriate fluid movement and vertigo when the head changes position.

Some of the key benefits of the Epley maneuver include:

• High success rate in resolving symptoms of BPPV, as reported in the studies 1.
• Low risk of complications, as stated in the guidelines 1.
• Ability to be performed in an outpatient setting, as mentioned in the studies 1.
• Potential to reduce the need for medication and other treatments, as recommended by the guidelines 1.

Overall, the treatment of BPPV should be individualized and based on the specific needs and circumstances of each patient, as recommended by the guidelines 1.

From the Research

Treatment Guidelines for Benign Paroxysmal Positional Vertigo (BPPV)

The treatment guidelines for BPPV involve various maneuvers to help alleviate symptoms. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers 2.

Types of Maneuvers

• Posterior canal BPPV can be treated with the Epley or Semont maneuvers, which have comparable efficacy and ease of performance 3, 4.
• Horizontal canal BPPV can be treated with the Gufoni maneuver or the BBQ roll (also known as Lempert 360 roll or log roll) 4.
• Anterior canal BPPV, although rare and generally short-lived, may be treated with deep head hanging maneuvers or various eponymous maneuvers, although the evidence for these is weaker 4.

Factors Influencing Treatment Choice

The choice of maneuver depends on several factors, including:

• Clinician preference
• Complexity of the maneuvers
• Poor treatment response to specific maneuvers
• Musculoskeletal considerations, such as arthritic changes and range of motion of the cervical spine 2, 4

Additional Considerations

• Daily treatment may provide earlier relief than weekly treatment, especially in apogeotropic BPPV 5.
• Patients with apogeotropic and multi-canal BPPV may require more follow-ups than those with posterior semicircular canal BPPV 5.
• The overall 1-year recurrence rate for BPPV is around 16%, with a higher recurrence rate related to trauma 5.
• Chair-assisted treatment may be helpful if available, while surgical canal plugging should be indicated in selected cases of intractable severe BPPV 2.