What are the management options for benign positional vertigo (BPV)?

Management of Benign Positional Vertigo (BPV)

Patients with benign paroxysmal positional vertigo (BPPV) should be treated with canalith repositioning procedures (CRPs) as first-line therapy rather than medications or observation alone. 1

Diagnosis

1. Posterior Canal BPPV (most common):

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

2. Lateral (Horizontal) Canal BPPV:

   • If Dix-Hallpike test shows horizontal or no nystagmus, perform a supine roll test 1
   • Supine roll test: patient lies supine with head turned 90° to each side sequentially

3. Differential Diagnosis:

   • Rule out other causes of vertigo (central vertigo, vestibular neuritis, Ménière's disease) 1
   • Assess for modifying factors: impaired mobility/balance, CNS disorders, fall risk 1

Treatment Algorithm

First-Line Treatment:

1. Posterior Canal BPPV:

   • Canalith Repositioning Procedure (CRP) - Epley maneuver 1
   • Success rate: 87% of patients can be cured with this procedure 2
   • Number needed to treat: 3 patients 3

2. Lateral Canal BPPV:

   • Barbecue roll maneuver or Gufoni maneuver

Important Treatment Considerations:

• No postprocedural restrictions needed after CRP (strong recommendation against) 1
• Do not routinely prescribe vestibular suppressant medications such as antihistamines or benzodiazepines 1
• Avoid radiographic imaging in patients meeting diagnostic criteria for BPPV without additional concerning symptoms 1
• Avoid vestibular testing in straightforward BPPV cases 1

Second-Line Options:

1. Vestibular Rehabilitation:

   • May be offered either self-administered or with a clinician 1
   • Includes habituation exercises, adaptation exercises, and balance training

2. Observation with Follow-up:

   • May be considered as initial management 1
   • BPPV can resolve spontaneously in approximately 20% of patients by 1 month and up to 50% by 3 months 1

3. Medication (only for symptom control, not as primary treatment):

   • Meclizine (25-100 mg daily in divided doses) only for short-term symptom management of severe vertigo 4
   • Caution: Causes drowsiness; patients should avoid driving and alcohol 4

Follow-Up and Monitoring

1. Reassess within 1 month after initial treatment to document resolution or persistence 1

2. For treatment failures:

   • Evaluate for unresolved BPPV
   • Consider underlying peripheral vestibular or central nervous system disorders 1
   • Repeat repositioning maneuvers

3. Patient Education:

   • Inform about potential for disease recurrence (common)
   • Discuss impact on safety (increased fall risk)
   • Emphasize importance of follow-up 1

Special Considerations

• Elderly patients are at increased risk for falls, depression, and impairments of daily activities due to BPPV 1
• Cost implications: Untreated BPPV leads to significant healthcare costs (approximately $2000 per diagnosis) 1
• Quality of life impact: 86% of patients suffer interrupted daily activities and lost work days due to BPPV 1

Common Pitfalls to Avoid

1. Overuse of vestibular suppressant medications - these mask symptoms but don't treat the underlying cause 1
2. Unnecessary imaging - not indicated for typical BPPV 1
3. Failure to perform diagnostic maneuvers correctly - leads to missed diagnosis
4. Not referring for repositioning maneuvers when unable to perform them
5. Missing central causes of positional vertigo - look for additional neurological symptoms

BPPV is highly treatable with proper diagnosis and management. The Epley maneuver and other repositioning procedures provide immediate and long-lasting relief for most patients, significantly improving quality of life and reducing fall risk.