What are the recommended maneuvers for Benign Paroxysmal Positional Vertigo (BPPV)?

Recommended Maneuvers for Benign Paroxysmal Positional Vertigo (BPPV)

For BPPV treatment, clinicians should perform canalith repositioning procedures (CRPs) as first-line therapy, with the Epley maneuver being the most effective for posterior canal BPPV (80-90% success rate), while the Gufoni or Barbecue Roll maneuvers are recommended for lateral canal BPPV. 1, 2

Posterior Canal BPPV Treatment

Epley Maneuver (Canalith Repositioning Procedure)

The Epley maneuver is the gold standard treatment for posterior canal BPPV with a 90.7% success rate after initial treatment 2:

1. Position patient upright with head turned 45° toward the affected ear
2. Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
3. Turn head 90° toward unaffected side and hold for 20 seconds
4. Turn head and body another 90° (face-down position) and hold for 20-30 seconds
5. Return patient to upright sitting position 1

Liberatory Maneuver (Semont Maneuver)

An alternative to the Epley maneuver with comparable effectiveness:

• Involves rapid movement from sitting to side-lying position
• Requires more abrupt movements than the Epley maneuver
• May be more difficult for elderly patients or those with mobility issues 1

Lateral Canal BPPV Treatment

For Geotropic Type:

• Barbecue Roll Maneuver (Lempert): 75-90% effectiveness 1, 2

  1. Start from supine position
  2. Roll to the involved side
  3. Roll head/body to unaffected side
  4. Continue rolling until head is nose down
  5. Complete full 360° roll and return to sitting

• Gufoni Maneuver: 93% success rate 1, 2

  1. From sitting, move to side-lying position on unaffected side for 30 seconds
  2. Quickly turn head toward ground 45°-60° and hold for 1-2 minutes
  3. Return to sitting with head held toward affected shoulder until fully upright

For Apogeotropic Type:

• Modified Gufoni Maneuver:
  1. From sitting, move to side-lying position on affected side for 30 seconds
  2. Quickly turn head toward ground 45°-60° and hold for 1-2 minutes
  3. Return to sitting with head held toward unaffected shoulder until fully upright 1

Self-Administered Treatment Options

Self-administered CRP (modified Epley) appears more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 1. One trial showed self-administered CRP resulted in 95% resolution of positional nystagmus after one week, compared to 58% for self-administered Semont maneuver 1.

Important Clinical Considerations

• Treatment Efficacy: The number-needed-to-treat with the Epley maneuver is 3 patients to achieve complete resolution of vertigo 3
• Recurrence Rate: BPPV has a high recurrence rate of approximately 36% after treatment 4
• Post-Procedure Care: Postprocedural restrictions are NOT recommended after CRP 1
• Follow-up: Patients should be reassessed within 1 month to document resolution or persistence of symptoms 2
• Vestibular Testing: Not routinely recommended for typical BPPV but should be considered for patients with:
  • Atypical nystagmus
  • Suspected additional vestibular pathology
  • Failed response to CRP
  • Frequent recurrences of BPPV 1

Treatment Algorithm

1. Identify the affected canal and type:

   • Posterior canal: Positive Dix-Hallpike test
   • Lateral canal: Positive supine roll test (determine if geotropic or apogeotropic)

2. Select appropriate maneuver:

   • Posterior canal → Epley maneuver (first choice) or Semont maneuver
   • Lateral canal geotropic → Gufoni maneuver (first choice) or Barbecue Roll
   • Lateral canal apogeotropic → Modified Gufoni maneuver

3. Evaluate treatment response:

   • If symptoms resolve → No further immediate treatment needed
   • If symptoms persist → Repeat maneuver or try alternative maneuver
   • If multiple failures → Consider vestibular function testing

The evidence strongly supports CRPs as the primary treatment for BPPV, with medications playing little to no role in routine management 1, 2, 3.