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

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) should be the first-line treatment for BPPV, with the specific maneuver chosen based on the affected semicircular canal. 1

Diagnosis and Canal Identification

Before treatment, proper diagnosis and identification of the affected canal is essential:

• Posterior Canal BPPV (most common, 88%): Diagnosed with Dix-Hallpike test showing torsional, upbeating nystagmus 1
• Horizontal Canal BPPV (10%): Diagnosed with supine roll test showing horizontal nystagmus 1
• Anterior Canal BPPV (rare, 2%): Diagnosed with Dix-Hallpike test showing specific nystagmus pattern 2

Treatment Algorithm by Canal Type

1. Posterior Canal BPPV Treatment

• First-line: Canalith Repositioning Procedure (CRP/Epley maneuver) 1

  • Success rate: 80-98% with 1-3 treatments 1, 3
  • Technique:
    1. Patient seated upright, head turned 45° toward affected ear
    2. Rapidly move to supine position with head hanging 20° off table edge (20-30 seconds)
    3. Turn head 90° toward unaffected side (20 seconds)
    4. Roll body and head another 90° to face-down position (20-30 seconds)
    5. Return to sitting position

• Alternative: Semont/Liberatory maneuver (comparable efficacy to Epley) 1, 4

2. Horizontal Canal BPPV Treatment

• First-line: Roll maneuver (Lempert/Barbecue roll) or Gufoni maneuver 1, 4
  • Success rate: 86-100% with up to 4 treatments 1
  • Gufoni maneuver is easier to perform as it only requires identifying the side of weaker nystagmus 4

3. Anterior Canal BPPV Treatment

• First-line: Deep head hanging maneuvers 4
  • Generally self-limiting but maneuvers may hasten recovery

Treatment Protocol Recommendations

• Initial treatment session: Perform 1-3 CRPs until nystagmus resolves 5
• Follow-up: Reassess within 1 month to document resolution or persistence 1
• Persistent symptoms: Repeat CRP (success rate increases to 90-98% with additional maneuvers) 1
• Multiple treatment failures: Consider canal conversion (6% of cases may convert between posterior and lateral canal BPPV) or CNS disorders 1

Important Considerations

• No postprocedural restrictions needed after CRP 1

• Avoid medications: Vestibular suppressants like meclizine should not be routinely used for BPPV treatment 1, 6

  • Meclizine is indicated for vertigo associated with vestibular diseases 7 but is not recommended as primary treatment for BPPV
  • Side effects include drowsiness, dry mouth, and potential anticholinergic effects 7

• Self-treatment option: Motivated patients can be taught self-repositioning maneuvers 1

• Higher recurrence risk in elderly patients, those with head trauma history, or vestibular neuropathy 3

Treatment Failures

If symptoms persist after multiple CRPs:

1. Re-evaluate for correct canal identification
2. Check for canal conversion (6% of cases)
3. Consider coexisting vestibular disorders
4. Rule out CNS disorders masquerading as BPPV (3% of treatment failures) 1

Surgical Options

For extremely refractory cases (rare), surgical plugging of the involved posterior semicircular canal has >96% success rate, but quality of evidence limits definitive recommendations 1.

The evidence strongly supports CRPs as the most effective treatment for BPPV, with high success rates, minimal side effects, and significant improvement in quality of life compared to medication or observation alone.