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

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

The Canalith Repositioning Procedure (Epley maneuver) should be used as first-line treatment for posterior canal BPPV, with success rates of 61-95% after a single treatment. 1, 2

Diagnosis and Classification

Before treatment, proper diagnosis is essential:

• BPPV is characterized by brief positional vertigo lasting seconds without hearing symptoms
• Triggered by specific head movements: rolling over in bed, tilting head upward, bending forward, lying down or getting up
• Diagnosis confirmed with:
  • Dix-Hallpike maneuver for posterior canal BPPV (most common form)
  • Supine roll test for horizontal canal BPPV

First-Line Treatment Options

Posterior Canal BPPV (Most Common)

1. Canalith Repositioning Procedure (Epley maneuver)

   • Most effective first-line treatment with 6.5 times greater chance of symptom improvement compared to controls 1
   • Success rate: 61-95% after a single treatment 2
   • Procedure:
     • Patient seated upright, head turned 45° toward affected ear
     • Patient rapidly laid back to supine head-hanging position (20°) for 20-30 seconds
     • Head turned 90° toward unaffected side, held for 20 seconds
     • Head turned another 90° (with body moving to lateral position), held for 20-30 seconds
     • Patient returned to upright sitting position

2. Liberatory Maneuver (Semont maneuver)

   • Alternative effective treatment with success rates of 71-94% 2
   • Particularly useful for patients with limited neck mobility

Horizontal Canal BPPV

1. Barbecue Roll Maneuver (Lempert maneuver)

   • Most commonly used for horizontal canal BPPV 1
   • Involves rolling patient 360° in sequential steps
   • Success rates similar to Epley for posterior canal BPPV

2. Gufoni Maneuver

   • Alternative treatment with success rates of 71-94% 2

Anterior Canal BPPV (Rare)

• Specialized repositioning maneuvers involving sequential head positioning 3
• Begin supine with head hanging 30° dependent, then supine with head inclined 30° forward, ending sitting with head 30° forward

Second-Line and Adjunctive Treatments

1. Vestibular Rehabilitation

   • May be offered as initial or adjunctive therapy 1
   • Less effective than repositioning maneuvers
   • Single CRP is >10 times more effective than a week of Brandt-Daroff exercises 1

2. Self-administered Repositioning Maneuvers

   • Self-administered CRP appears more effective (64% improved) than self-treatment with Brandt-Daroff exercises (23% improvement) 1
   • Option for motivated patients or those with recurrent BPPV

3. Observation

   • May be appropriate for patients with mild symptoms
   • Natural resolution occurs in 20-30% of untreated cases within 1 month 2
   • Not recommended for elderly patients, those with preexisting balance disorders, or individuals at high risk for falls 1

Important Considerations

1. Postprocedural Restrictions

   • Not recommended after CRP for posterior canal BPPV 1
   • Strong recommendation against restrictions based on RCTs

2. Treatment Failures

   • Repeat the appropriate maneuver
   • Consider alternative maneuvers
   • Consider self-administered exercises for motivated patients
   • Evaluate for additional vestibular pathology

3. Follow-up

   • Reassessment within 1 month to confirm symptom resolution 2
   • Recurrence rate of approximately 36% 2

4. Medication

   • Routine use of vestibular suppressants NOT recommended as primary treatment 2, 4
   • Particle repositioning maneuvers have substantially higher treatment response (78.6%-93.3%) compared to medication alone (30.8%) 2

Special Populations

• Patients with physical limitations (cervical stenosis, severe rheumatoid arthritis, etc.) may require modified techniques or specialized examination tables 1, 2
• Consider alternative maneuvers like the Li maneuver for patients with limited cervical spine movement, which shows similar efficacy to the Epley maneuver 5

Treatment Algorithm

1. Confirm diagnosis with appropriate positional testing
2. Identify canal involved (posterior, horizontal, anterior)
3. Perform appropriate repositioning maneuver based on canal involvement
4. Reassess immediately after maneuver
5. If symptoms persist, repeat maneuver up to 3 times in one session 6
6. Schedule follow-up within one month
7. For recurrent or resistant cases, consider vestibular rehabilitation or self-administered exercises

This approach will reduce unnecessary testing, medication use, and improve patient outcomes with rapid symptom resolution.