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

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) are the first-line treatment for BPPV, with success rates of 80-98%, and should be used instead of medications. 1

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis and identify the affected canal:

• Posterior canal BPPV: Diagnosed when vertigo with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 2
• Lateral canal BPPV: Assessed using the supine roll test when Dix-Hallpike shows horizontal or no nystagmus 2

First-Line Treatments by Canal Type

Posterior Canal BPPV (Most Common, ~80% of cases)

1. Canalith Repositioning Procedure (Epley maneuver):

   • Success rate: 61-95% after a single treatment 2
   • Technique:
     • Patient seated upright, head turned 45° toward affected ear
     • Rapidly move to supine head-hanging position for 20-30 seconds
     • Turn head 90° toward unaffected side, hold 20 seconds
     • Turn head and body another 90° (face-down position), hold 20-30 seconds
     • Return to sitting position 2

2. Liberatory Maneuver (Semont maneuver):

   • Success rate: 71-94% 2
   • Technique:
     • Start with patient sitting, head turned 45° away from affected side
     • Quickly move to side-lying position toward affected side with head turned up
     • Hold until nystagmus ceases (at least 20 seconds)
     • Quickly move through sitting to opposite side-lying position with head facing down
     • Hold 30 seconds, then slowly return to sitting 2

Lateral (Horizontal) Canal BPPV

1. Gufoni Maneuver:

   • For geotropic type (most common):

     • Start sitting, then lie on affected side for 30 seconds
     • Turn head 45-60° downward, hold 1-2 minutes
     • Return to sitting with head toward unaffected shoulder 2

   • For apogeotropic type:

     • Start sitting, then lie on affected side for 30 seconds
     • Turn head 45-60° downward, hold 1-2 minutes
     • Return to sitting 2

2. Barbecue Roll Maneuver (Lempert maneuver):

   • Involves rolling the patient 360° in a series of steps 2
   • Success rate: 75-90% 2

Treatment Protocol

1. Initial treatment:

   • Perform appropriate repositioning maneuver based on canal type
   • May repeat 2-3 times in a single session if symptoms persist 2

2. Follow-up:

   • Reassess within 1 month to confirm symptom resolution 2
   • For persistent symptoms, evaluate for:
     • Incorrect diagnosis
     • Wrong canal identification
     • Multiple canal involvement
     • Other vestibular disorders 2

3. For treatment failures:

   • Repeat the appropriate maneuver
   • Consider alternative maneuvers
   • Consider self-administered exercises for motivated patients 2

Important Considerations

• No postprocedural restrictions needed: Strong evidence shows that postural restrictions after CRP do not improve outcomes 2

• Medications are NOT recommended as primary treatment for BPPV:

  • Vestibular suppressants (antihistamines, benzodiazepines) should not be routinely used 2
  • Meclizine may provide temporary symptomatic relief for severe nausea but does not treat the underlying condition 1, 3

• Self-administered treatments:

  • Self-administered CRP shows 64% improvement vs. 23% for Brandt-Daroff exercises 2
  • Can be taught to motivated patients for recurrent BPPV 2

• Observation as initial management:

  • May be appropriate for some patients with mild symptoms
  • Natural resolution occurs in 20-30% of untreated cases within 1 month 2
  • Must ensure proper follow-up 2

Special Considerations

• Physical limitations: Patients with cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, or other musculoskeletal issues may require modified techniques 2

• Recurrence: BPPV has a recurrence rate of approximately 36% 4, so patient education about potential recurrence is essential

• Fall risk: BPPV increases fall risk, especially in older adults, making prompt and effective treatment crucial 2

By following this evidence-based approach to BPPV treatment, clinicians can achieve high success rates with minimal risk, significantly improving patients' quality of life and reducing morbidity associated with falls and persistent vertigo.