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

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs), particularly the Epley maneuver, are the first-line treatment for BPPV with success rates of 61-95% after a single treatment. 1

Diagnosis and Initial Assessment

• Diagnosis requires:
  • Dix-Hallpike test for posterior canal BPPV (most common form)
  • Supine roll test for horizontal canal BPPV when Dix-Hallpike is negative 1
• Routine radiographic imaging or vestibular testing is NOT recommended for clear BPPV diagnosis 1

Treatment Options by Canal Type

Posterior Canal BPPV (Most Common)

1. First-line: Canalith Repositioning Procedure (Epley maneuver)

   • Success rates of 61-95% after a single treatment 1
   • 91% of posterior canal BPPV cases can be effectively treated with 2 maneuvers or less 2
   • Meta-analysis shows 7.19 times higher odds of complete vertigo resolution at 1 week compared to control (moderate certainty evidence) 3
   • Number-needed-to-treat is 3 3

2. Alternative Repositioning Maneuvers:

   • Liberatory Maneuver (Semont maneuver) - comparable effectiveness to Epley 4
   • Gans Maneuver - comparable effectiveness to Epley 1, 4
   • Brandt-Daroff exercises - less effective than Epley (OR 12.38 favoring Epley) 4

Horizontal Canal BPPV

1. First-line: Barbecue Roll Maneuver (Lempert maneuver)

   • 88% of horizontal canal BPPV cases can be effectively treated with 2 treatments 2
   • Success rates ranging from 71-94% 1

2. Alternative: Gufoni Maneuver

   • Particularly effective for apogeotropic variant 1

Special Considerations

• Complex Cases:

  • Bilateral posterior canal BPPV, multiple canal involvement, or canal conversions require more treatments 2
  • Canal conversions can occur in approximately 6% of cases (posterior to lateral or lateral to posterior) 5

• Treatment Failures:

  • Reevaluation is necessary for persistent symptoms 5
  • Repeat repositioning maneuvers can increase success rates to 90-98% 5
  • For cases refractory to multiple CRPs, surgical options like canal plugging may be considered, though data quality is insufficient for definitive recommendations 5

• Post-Treatment Management:

  • Postprocedural restrictions are NOT recommended after CRP for posterior canal BPPV 1
  • Reassessment within 1 month is recommended to confirm symptom resolution 1

• Potential Side Effects:

  • 19% of patients may experience post-treatment down-beating nystagmus and vertigo ("otolithic crisis") after treatment 2
  • Nausea during repositioning maneuvers occurs in 16.7-32% of patients 4
  • Some patients with cervical spine problems may be unable to tolerate the maneuvers 4

Medication Options

• Medications are NOT first-line treatment for BPPV
• Meclizine (25-100 mg daily in divided doses) may be used for symptomatic relief of vertigo but does not treat the underlying cause 6
• Caution: Meclizine may cause drowsiness and has anticholinergic effects 6

Patient Education and Follow-up

• Recurrence rate of BPPV is approximately 36%, highlighting the importance of patient education 1
• Reassessment within 1 month after treatment is recommended 1
• Self-administered repositioning maneuvers appear more effective (64% improved) than self-treatment with Brandt-Daroff exercises (23% improvement) 1

BPPV is highly treatable with proper diagnosis and management. The Epley maneuver and other repositioning techniques offer a safe, effective, and medication-free approach to resolving symptoms in most patients.