What are the management options for Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

The most effective management option for Benign Paroxysmal Positional Vertigo (BPPV) is the canalith repositioning procedure, which should be performed by a clinician or referred to a clinician who can treat patients with posterior canal BPPV. This recommendation is based on the strongest evidence from the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1. The guideline strongly recommends treating patients with posterior canal BPPV with a canalith repositioning procedure, which is a non-invasive and effective treatment option.

Key Management Options

• Canalith repositioning procedure (Epley maneuver or Semont maneuver) for posterior canal BPPV
• Roll maneuver (Lempert or barbecue maneuver) for horizontal canal BPPV
• Vestibular rehabilitation exercises for patients with residual symptoms or difficulty with balance
• Observation with follow-up as initial management for patients with BPPV

Important Considerations

• Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 1
• Clinicians should assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling 1
• Patient education is crucial in managing BPPV, including discussing the impact of BPPV on daily life, diagnosis and treatment options, and risk for recurrence 1

Treatment Outcomes

• Most BPPV cases resolve with proper repositioning techniques, though recurrence occurs in about 15-50% of patients
• Clinicians should reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms 1
• Patients should be counseled regarding the importance of follow-up after the diagnosis of BPPV and the potential for recurrence 1

From the Research

Management Options for BPPV

The management options for Benign Paroxysmal Positional Vertigo (BPPV) include:

• Repositioning maneuvers, such as the Epley maneuver, Semont maneuver, and Gufoni maneuver, which are highly effective in treating BPPV 2, 3, 4, 5, 6
• Vestibular exercises, such as Brandt-Daroff exercises, which can also be effective in managing BPPV 3
• Surgery, which has a minor role in the management of BPPV 2
• Medications, which may transiently ameliorate symptoms but do not treat the underlying process 2

Repositioning Maneuvers

The choice of repositioning maneuver depends on the canal involved and the clinician's preference:

• For posterior canal BPPV, the Epley and Semont maneuvers are effective and comparable in terms of efficacy and ease of performance 2, 4
• For horizontal canal BPPV, the Gufoni maneuver and BBQ roll (also known as Lempert 360 roll or log roll) are effective, with the Gufoni maneuver being easier to perform 2
• For anterior canal BPPV, deep head hanging maneuvers may be effective, although the evidence is weaker 2

Efficacy of Repositioning Maneuvers

The Epley maneuver has been shown to be effective in resolving vertigo symptoms and converting a positive Dix-Hallpike test to a negative test:

• A systematic review of 11 randomized controlled trials found that the Epley maneuver was associated with complete resolution of vertigo in 56% of patients, compared to 21% in the control group 4
• A meta-analysis of 4 randomized controlled trials found that the Epley maneuver was associated with higher complete resolution of vertigo at 1 week, with a number-needed-to-treat of 3 5