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

Initial Treatment for Benign Paroxysmal Positional Vertigo (BPPV)

Clinicians should treat patients with posterior canal BPPV with a canalith repositioning procedure (CRP), also known as the Epley maneuver, as the initial treatment of choice.

Diagnosis and Classification

Before initiating treatment, proper diagnosis is essential:

1. Posterior Canal BPPV (most common form):

   • Diagnosed when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 1
   • Perform by bringing the patient from upright to supine position with head turned 45° to one side and neck extended 20° with the affected ear down

2. Lateral (Horizontal) Canal BPPV:

   • If Dix-Hallpike test shows horizontal or no nystagmus despite BPPV symptoms, perform a supine roll test 1
   • Different repositioning maneuvers are required for this variant

Treatment Algorithm

First-Line Treatment:

• Canalith Repositioning Procedure (Epley maneuver) for posterior canal BPPV 1
  • Strong recommendation based on high-quality evidence
  • Success rate of 90-98% when performed correctly 1
  • Number needed to treat is 3 2

Performance of Epley Maneuver:

1. Place patient in upright position with head turned 45° toward affected ear
2. Rapidly move patient to supine head-hanging position for 20-30 seconds
3. Turn head 90° toward unaffected side and hold for 20 seconds
4. Turn head and body another 90° (face-down position) and hold for 20-30 seconds
5. Return patient to sitting position 1

Important Clinical Considerations:

• No postprocedural restrictions are necessary after CRP (strong recommendation against restrictions) 1
• Multiple CRPs may be performed in a single session until symptoms resolve or Dix-Hallpike converts to negative 1
• Do not routinely prescribe vestibular suppressant medications such as antihistamines or benzodiazepines 1

Alternative Initial Management Options:

1. Observation with follow-up may be offered as initial management (option) 1

   • Spontaneous resolution occurs in approximately 20% of patients at 1 month and up to 50% at 3 months 1
   • However, this approach prolongs symptoms compared to active treatment

2. Vestibular rehabilitation may be offered, either self-administered or with a clinician (option) 1

   • Less effective than CRP but may be considered in certain cases

Follow-Up and Treatment Failure

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 1
• For persistent symptoms:
  1. Re-evaluate for unresolved BPPV (may require additional CRP)
  2. Consider other peripheral vestibular or CNS disorders 1
  3. Consider referral to specialist if symptoms persist after 2-3 attempted maneuvers 1

Common Pitfalls to Avoid

1. Unnecessary imaging: Do not obtain radiographic imaging in patients meeting diagnostic criteria for BPPV without additional concerning symptoms 1
2. Unnecessary vestibular testing: Do not order vestibular testing without additional vestibular symptoms inconsistent with BPPV 1
3. Medication overuse: Avoid vestibular suppressants which can delay central compensation and prolong recovery 1
4. Inadequate patient education: Counsel patients regarding safety concerns, potential for recurrence (15% per year), and importance of follow-up 1

The Epley maneuver has been demonstrated to be highly effective with an odds ratio of 4.42 (95% CI 2.62 to 7.44) for complete resolution of vertigo compared to sham or control interventions 3. It is safe, cost-effective, and provides immediate relief in many cases, making it the clear first choice for initial BPPV management.