What is the treatment for benign paroxysmal positional vertigo (BPPV)?

From the Guidelines

The primary treatment for benign paroxysmal positional vertigo (BPPV) is a canalith repositioning procedure, such as the Epley maneuver, which should be performed by a healthcare provider or a clinician who can treat patients with posterior canal BPPV, as recommended by the clinical practice guideline update 1. This procedure involves a series of head and body movements to relocate displaced calcium crystals from the semicircular canals back to the utricle where they belong. The Epley maneuver is most effective for posterior canal BPPV, while horizontal canal BPPV may require the Lempert (BBQ roll) maneuver. These procedures can be performed by healthcare providers and often taught to patients for home treatment. Some key points to consider when treating BPPV include:

• The Epley maneuver typically involves sitting upright, turning the head 45 degrees toward the affected ear, quickly lying back with the head hanging slightly off the examination table, turning the head 90 degrees to the opposite side, rolling onto that side while turning the head another 90 degrees, and finally returning to a sitting position.
• Medications like meclizine, dimenhydrinate, or promethazine may provide temporary symptom relief but don't treat the underlying cause.
• Most patients experience significant improvement after 1-3 treatments, though some may require multiple sessions.
• BPPV works because it repositions the displaced otoconia (calcium carbonate crystals) that have migrated into the semicircular canals, where they disrupt the normal fluid movement that helps maintain balance, causing the characteristic spinning sensation when the head changes position, as explained in the clinical practice guideline update 1. It's also important to note that clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, and clinicians should not order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, as stated in the guideline update 1. Additionally, clinicians should educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up, as recommended in the guideline update 1. Overall, the treatment of BPPV should be guided by the clinical practice guideline update, which provides recommendations for diagnosis, treatment, and follow-up care, as well as patient education and safety considerations.

From the FDA Drug Label

MECLIZINE HYDROCHLORIDE tablets, for oral use Initial U. S. Approval: 1957 INDICATIONS AND USAGE Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1).

The treatment for benign paroxysmal positional vertigo (BPPV) may include meclizine, as it is 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 2.
• Key consideration: Meclizine hydrochloride tablets are contraindicated in patients with hypersensitivity to meclizine or any of the inactive ingredients.
• Important warning: May cause drowsiness, use caution when driving a car or operating dangerous machinery 2.

From the Research

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

• The primary evidence-based treatment strategy for BPPV is physical therapy through maneuvers, including the Epley, Semont, and Gufoni maneuvers 3, 4.
• These maneuvers are highly effective in treating BPPV, with a high success rate, and are considered the first line of treatment 5, 6.
• The choice of maneuver depends on the clinician's preference, the patient's movement restrictions, and the failure of previous maneuvers 3, 4.
• For posterior canal BPPV, the Epley and Semont maneuvers are comparable in efficacy and ease of performance 4, 6.
• For horizontal canal BPPV, the Gufoni maneuver and BBQ roll are effective treatments, with the Gufoni maneuver being easier to perform 4.
• Anterior canal BPPV is rare and generally short-lived, but deep head hanging maneuvers may hasten recovery, although the evidence is weaker 3, 4.

Efficacy and Recurrence Rates

• The Epley maneuver has been shown to be highly effective in treating posterior canal BPPV, with a recovery rate of 90.7% after the initial maneuver and 96% after the second maneuver 6.
• The recurrence rate for BPPV is relatively low, with 11% of patients experiencing a recurrent attack within the first year after successful treatment 6.
• Elderly patients and those with a history of head trauma or vestibular neuropathy have a higher recurrence rate, requiring additional education to minimize potential morbidity 5.

Other Treatment Considerations

• Surgical canal plugging may be indicated in selected cases of intractable, severe BPPV, but this is a rare and last-resort option 3.
• Chair-assisted treatment may be helpful if available, but the evidence for this is limited 3.
• Medications may transiently ameliorate symptoms, but they do not treat the underlying process, and repositioning maneuvers are the preferred treatment 4.