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) is the first-line treatment for BPPV, with success rates of 61-95% after a single treatment, and should be performed for all patients with confirmed BPPV. 1

Diagnosis and Confirmation

• Diagnosis is confirmed by a positive Dix-Hallpike maneuver for posterior canal BPPV
• Supine roll test is used for horizontal canal BPPV when Dix-Hallpike is negative 1
• These diagnostic tests are essential before proceeding with treatment

First-Line Treatment Options

Canalith Repositioning Procedures

1. Posterior Canal BPPV (most common):

   • Epley maneuver - first-line treatment with 61-95% success rate after a single treatment 1
   • Semont maneuver (Liberatory Maneuver) - alternative with 71-94% success rate 1, 2

2. Horizontal Canal BPPV:

   • Gufoni Maneuver - level 1 evidence treatment 2
   • Barbecue Roll Maneuver (Lempert maneuver) - success rate of 71-94% 1

3. Treatment Protocol:

   • Repeat procedures can increase success to 90-98% 1
   • Patients should be reassessed within 1 month after treatment 1
   • Multiple treatments in the same session are safe and effective 3

Second-Line and Adjunctive Treatments

Medication

• Meclizine (25-100 mg daily in divided doses) for vertigo symptoms 4
• Important limitation: Vestibular suppressants should be limited to short-term use (<1 week) to avoid interference with vestibular compensation 1
• Use only for:
  • Severe autonomic symptoms
  • Patients who refuse repositioning maneuvers
  • Severe symptoms after repositioning maneuvers 1

Other Approaches

• Vestibular rehabilitation - less effective than repositioning maneuvers for BPPV but may be offered for chronic imbalance after acute phase resolution 1
• Redistribution exercises - can be used in combination with repositioning maneuvers 5

Special Considerations

Contraindications to Repositioning Maneuvers

• Cervical stenosis
• Severe rheumatoid arthritis
• Cervical radiculopathies 1

Potential Adverse Effects

• Nausea during repositioning (reported in 16.7-32% of patients) 1, 6
• Post-treatment down-beating nystagmus and vertigo ("otolithic crisis") may occur after treatment 3
• No serious adverse effects reported in clinical trials 6

Management of Persistent or Recurrent BPPV

• Recurrence rate is approximately 36% 1, 7
• For persistent cases:
  • Consider aquatic physiotherapy for vestibular rehabilitation 7
  • Evaluate for multiple canal involvement 2
  • Assess for associated comorbidities (migraine, persistent postural perceptual dizziness) 2
  • Check for risk factors (low vitamin D serum level) 2
• Surgical canal plugging should be considered only in selected same-canal, same-side intractable severe BPPV cases 2

Patient Education

• Provide information about safety concerns related to BPPV
• Discuss potential for disease recurrence (approximately 36%)
• Emphasize importance of follow-up 1
• Recommend lifestyle modifications:
  • Sodium restriction
  • Avoiding excessive caffeine, alcohol, and nicotine
  • Managing stress
  • Getting adequate sleep 1

Treatment Algorithm

1. Confirm diagnosis with appropriate positioning tests
2. Identify canal involved (posterior vs. horizontal)
3. Perform appropriate repositioning maneuver based on canal involvement
4. If unsuccessful after first attempt, repeat maneuver in same session
5. Limit vestibular suppressants to short-term use only when absolutely necessary
6. Schedule follow-up within one month to assess response
7. For persistent cases, consider alternative maneuvers or specialized referral