How is Benign Paroxysmal Vertigo (BPV) treated?

Treatment of Benign Paroxysmal Positional Vertigo (BPV)

Benign Paroxysmal Positional Vertigo (BPPV) should be treated with canalith repositioning procedures (CRPs), specifically the Epley maneuver for posterior canal BPPV, which is the most common form (85-95% of cases). 1

Diagnosis and Classification

Before treatment, proper diagnosis is essential:

1. Posterior Canal BPPV (most common, 85-95% of cases):

   • Diagnosed using the Dix-Hallpike test
   • Characterized by vertigo with torsional, upbeating nystagmus when the head is positioned with the affected ear down

2. Lateral (Horizontal) Canal BPPV (5-15% of cases):

   • Diagnosed using the supine roll test
   • Different treatment approach required

First-Line Treatment: Canalith Repositioning Procedures

For Posterior Canal BPPV: Epley Maneuver (CRP)

1. Patient is placed upright with head turned 45° toward the affected ear
2. Patient is rapidly laid back to supine head-hanging position (20-30 seconds)
3. Head is turned 90° toward the unaffected side (20 seconds)
4. Head is turned another 90° (with body turning to lateral position) until nearly face-down (20-30 seconds)
5. Patient returns to upright sitting position 1

The success rate for the Epley maneuver is high, with symptom resolution in approximately 80% of cases after 1-3 treatments 1. This procedure works by moving displaced calcium carbonate crystals (otoconia) from the semicircular canal back to their proper location in the utricle.

For Lateral Canal BPPV: Roll Maneuver

• The Lempert maneuver (barbecue roll) involves rolling the patient 360° in a series of steps 1

Alternative First-Line Treatment Options

1. Semont Liberatory Maneuver:

   • Another effective repositioning technique for posterior canal BPPV
   • Involves rapid movement between right and left side-lying positions 1

2. Vestibular Rehabilitation:

   • May be offered as initial therapy or in conjunction with repositioning maneuvers
   • Includes habituation exercises, adaptation exercises, and balance training 1

Important Considerations

• Avoid Vestibular Suppressant Medications: Guidelines strongly recommend against routinely treating BPPV with antihistamines (like meclizine) or benzodiazepines 1, 2

• Postural Restrictions: Post-procedural restrictions after CRP are not necessary 1

• Follow-up: If symptoms persist after initial treatment, patients should be re-evaluated as they may:

  1. Have a different type of BPPV requiring different maneuvers
  2. Have BPPV affecting multiple canals
  3. Need additional repositioning sessions 1

Self-Treatment Options

For motivated patients, self-administered repositioning maneuvers can be taught, though success rates may be lower than clinician-administered treatments 1. This approach has become increasingly relevant, with evidence supporting telehealth-guided treatment during situations like the COVID-19 pandemic 3.

Common Pitfalls to Avoid

1. Unnecessary Testing: Avoid routine vestibular testing or imaging for straightforward BPPV cases 1, 2

2. Medication Overuse: Vestibular suppressants like meclizine have side effects with little therapeutic benefit for BPPV 2

3. Inadequate Diagnosis: Failure to perform proper diagnostic maneuvers (Dix-Hallpike or supine roll test) leads to missed or incorrect diagnosis 2

4. Physical Limitations: Some patients may not be candidates for standard repositioning maneuvers due to physical limitations (cervical stenosis, severe arthritis, obesity, etc.) and may require modified approaches 1

BPPV typically resolves with proper treatment, though recurrence is possible. If left untreated, it may resolve spontaneously within weeks, but treatment is recommended to reduce fall risk, particularly in older adults 1.