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

Treatment for Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) are the first-line treatment for BPPV, with success rates of 80-96% after just 1-3 treatments. 1

Diagnosis and Canal Identification

Before treatment, proper identification of the affected canal is essential:

• Posterior canal BPPV (most common): Diagnosed with the Dix-Hallpike test
• Horizontal canal BPPV: Diagnosed with the Supine Roll test
• Anterior canal BPPV: Diagnosed by down-beating nystagmus in positional tests

Specific Repositioning Maneuvers by Canal Type

Posterior Canal BPPV (80-90% of cases)

1. Epley maneuver: First-line treatment with 90.7% success rate after initial attempt, increasing to 96% after second attempt 1
2. Semont maneuver: Alternative with comparable efficacy to Epley 2
3. Self-administered Epley: 64% improvement rate for home treatment 1
4. Brandt-Daroff exercises: Less effective (23% improvement) but can be used as supplementary home exercises 1

Horizontal Canal BPPV

1. Barbecue Roll Maneuver (Lempert): 75-90% effectiveness 1
2. Gufoni Maneuver: 93% success rate for geotropic type BPPV 1

Anterior Canal BPPV

• Specialized maneuver: Sequential head positioning from supine with head hanging 30° dependent, to supine with head inclined 30° forward, ending sitting with head 30° forward 3

Treatment Protocol

1. Initial treatment session:

   • Perform appropriate CRP based on affected canal
   • Repeat maneuver 1-2 times in same session if needed (safe and effective approach) 4
   • Note: Presence or absence of nystagmus during treatment does not predict success 4

2. Follow-up:

   • Reassess within 1 month to document resolution or persistence 1
   • If symptoms persist, repeat appropriate CRP
   • For refractory cases, consider alternative canal involvement or canal conversion

Important Clinical Considerations

• Medication use: Vestibular suppressants (meclizine, diazepam) should be limited to short-term use (<1 week) as they can interfere with vestibular compensation 1
• Post-treatment precautions: Monitor for "otolithic crisis" (post-treatment down-beating nystagmus and vertigo) which occurs in approximately 19% of patients after Epley maneuver 4
• Recurrence rate: BPPV has a high recurrence rate (36%) after successful treatment 2
• Special populations: Elderly patients require modified techniques and are at higher risk for falls 1

Treatment Efficacy Comparisons

• Epley maneuver is comparable in efficacy to Semont and Gans maneuvers 2
• Epley maneuver is superior to Brandt-Daroff exercises (OR 12.38,95% CI 4.32 to 35.47) 2
• Li maneuver shows similar efficacy to Epley maneuver and may be suitable for patients with limited cervical spine movement 5

Common Pitfalls to Avoid

1. Inappropriate management: Avoid routine brain imaging and vestibular suppressant medications which are not recommended by guidelines 6
2. Inadequate diagnosis: Failure to perform appropriate diagnostic tests (Dix-Hallpike or Supine Roll) leads to missed or incorrect diagnosis
3. Insufficient follow-up: Patients should be educated about potential recurrence and need for follow-up
4. Canal conversion: Be vigilant about potential conversion from one canal type to another during treatment 4
5. Cervical limitations: Some patients cannot tolerate standard maneuvers due to cervical spine problems; consider alternative approaches like the Li maneuver 5