From the Guidelines
The management of benign paroxysmal positional vertigo (BPPV) primarily involves the use of canalith repositioning procedures (CRPs), such as the Epley maneuver, as the initial treatment for posterior canal BPPV, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.
Diagnosis and Assessment
The diagnosis of BPPV is based on a combination of clinical history and physical examination, including the Dix-Hallpike test for posterior canal BPPV and the supine roll test for lateral canal BPPV 1. It is essential to differentiate BPPV from other causes of imbalance, dizziness, and vertigo, and to assess for factors that may modify management, such as impaired mobility or balance, central nervous system disorders, lack of home support, and increased risk for falling 1.
Treatment
- Canalith Repositioning Procedures (CRPs): CRPs, such as the Epley maneuver, are the recommended initial treatment for posterior canal BPPV, with a high success rate of 80-90% 1.
- Vestibular Rehabilitation Therapy: This may be offered as an initial treatment for BPPV, either self-administered or with a clinician, to promote neuroplasticity and help the brain compensate for vestibular deficits 1.
- Observation: Observation with follow-up may be considered as an initial management strategy for patients with BPPV, especially if symptoms are mild or if the patient is unable to undergo CRP 1.
Follow-Up and Reassessment
Patients should be reassessed within 1 month after an initial period of observation or treatment to confirm symptom resolution and to evaluate for persistent BPPV or underlying peripheral vestibular or central nervous system disorders 1. Counseling regarding the impact of BPPV on safety, the potential for disease recurrence, and the importance of follow-up is also crucial 1.
Additional Considerations
- Radiographic Imaging and Vestibular Testing: These should not be routinely obtained in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing 1.
- Vestibular Suppressant Medications: These should not be routinely used to treat BPPV, as they can delay central compensation and have limited efficacy in resolving symptoms 1.
From the FDA Drug Label
Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The management of benign paroxysmal positional vertigo (BPPV) is not directly addressed in the provided drug label. Key points:
- The label mentions treatment of vertigo associated with diseases affecting the vestibular system.
- It does not specifically mention BPPV or its management. 2
From the Research
Management of Benign Paroxysmal Positional Vertigo (BPPV)
The management of BPPV involves several approaches, including:
- Bedside tests such as the Dix-Hallpike test to diagnose BPPV 3
- The Epley maneuver, a bedside positional maneuver that relocates free floating particles from the affected semi-circular canals back into the utricle, thus relieving the symptoms of vertigo 3, 4, 5, 6
- The Epley maneuver has been shown to be a safe and effective treatment for posterior canal BPPV, with a significant effect in favor of the Epley maneuver over controls 5, 6
- The use of vestibular suppressant medications such as meclizine is not recommended by current guidelines, as they have little therapeutic effect and can have side effects 3
Efficacy of the Epley Maneuver
Studies have demonstrated the efficacy of the Epley maneuver in treating BPPV, including:
- A systematic review of systematic reviews that found the Epley maneuver to be associated with higher complete resolution of vertigo at 1 week and higher conversion to negative Dix-Hallpike at 1 week 6
- A prospective study that found the Epley maneuver to be an effective short-term treatment for subjective BPPV, with half of the patients experiencing resolution of symptoms 7
Approach to Patients with BPPV
The approach to patients with BPPV includes: