What is the treatment for benign postural vertigo (BPV)?

Treatment for Benign Positional Vertigo (BPV)

The first-line treatment for benign paroxysmal positional vertigo (BPPV) is a canalith repositioning procedure (CRP), specifically the Epley maneuver for posterior canal BPPV, which has a success rate of approximately 80% with just 1-3 treatments. 1

Diagnosis and Canal Identification

Before treatment, proper diagnosis is essential:

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

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

2. Lateral (horizontal) canal BPPV:

   • Diagnosed using the supine roll test if Dix-Hallpike shows horizontal or no nystagmus 1

Treatment Algorithm

For Posterior Canal BPPV:

1. Canalith Repositioning Procedure (Epley maneuver) 1:

   • Step 1: Patient sits upright with head turned 45° toward affected ear
   • Step 2: Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
   • Step 3: Turn head 90° toward unaffected side, hold for 20 seconds
   • Step 4: Turn head and body another 90° (patient nearly face-down), hold for 20-30 seconds
   • Step 5: Return patient to upright sitting position

2. Alternative: Liberatory Maneuver (Semont maneuver) 1:

   • Similar effectiveness to Epley (71-74% success rate at 1 week)
   • May be preferred for patients with mobility limitations that make Epley difficult

For Lateral Canal BPPV:

1. Barbecue Roll Maneuver (Lempert maneuver) or Gufoni Maneuver 1:
   • For geotropic type: Roll patient 360° in sequential steps
   • For apogeotropic type: Use modified Gufoni maneuver

Important Clinical Considerations

• No postprocedural restrictions needed: Strong evidence shows postural restrictions after CRP are unnecessary 1

• Avoid medications: Do not routinely treat BPPV with vestibular suppressant medications like antihistamines (meclizine) or benzodiazepines 1

  • Meclizine may cause drowsiness, dry mouth, and blurred vision without addressing the underlying cause 2

• Follow-up: Reassess patients within 1 month to document resolution or persistence of symptoms 1

• Self-administered treatment: Patients can be taught to perform self-repositioning maneuvers at home, particularly if they have recurrent BPPV 1

• Treatment failure considerations: If symptoms persist after properly performed maneuvers, consider:

  • Incorrect diagnosis
  • Wrong canal identified
  • Multiple canals involved
  • Associated comorbidities (migraine, other vestibular disorders) 3

Expected Outcomes

• Success rate: 80% resolution with 1-3 treatments 1
• Immediate effects: Some patients report immediate relief, while others experience continuing motion sickness-like symptoms for hours to days 1
• Recurrence rate: Approximately 36% of patients experience recurrence 4

Cautions and Contraindications

• Patients with severe neck problems, cervical stenosis, or unstable cardiovascular status may require modifications or alternative approaches
• Mild nausea during the procedure is common (16.7-32%) 4
• No serious adverse effects have been reported in clinical trials 1

The evidence clearly demonstrates that canalith repositioning procedures are the most effective treatment for BPPV, with significantly better outcomes than observation alone or medication use, and should be the first-line treatment for all patients with BPPV.