What are the treatments for benign paroxysmal positional vertigo (BPPV)?

From the Guidelines

The most effective treatment for benign paroxysmal positional vertigo (BPPV) is a canalith repositioning procedure, such as the Epley maneuver, which should be performed by a clinician or referred to a clinician who can treat patients with posterior canal BPPV 1. This procedure involves specific head movements to reposition inner ear crystals and has been shown to be effective in resolving symptoms of BPPV.

• The Epley maneuver is a series of movements that help to move the calcium particles out of the semicircular canals and into an area of the ear where they will not cause symptoms.
• The procedure is typically performed in a clinician's office and takes about 15-30 minutes to complete.
• It is essential to note that clinicians should not recommend postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV 1. In addition to the Epley maneuver, vestibular rehabilitation may be offered as an option for the treatment of BPPV 1, which can help train the brain to compensate for balance issues.
• Vestibular rehabilitation exercises can be self-administered or performed with a clinician.
• These exercises can help improve balance and reduce symptoms of vertigo. It is also important to note that clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines 1, as they have the potential for significant harm, including drowsiness, cognitive deficits, and increased risk of falls.
• However, in some cases, vestibular suppressant medications may be used for short-term management of autonomic symptoms, such as nausea or vomiting, in severely symptomatic patients.
• Antiemetics may also be considered for prophylaxis for patients who have previously manifested severe nausea and/or vomiting with the Dix-Hallpike maneuvers and in whom a canalith repositioning procedure is planned.

From the Research

Treatments for Benign Paroxysmal Positional Vertigo (BPPV)

• The Epley maneuver is considered the primary treatment for BPPV, as it has been shown to be effective in resolving symptoms and converting a positive Dix-Hallpike test to a negative one 2, 3.
• Anti-vertigo medications such as betahistine and dimenhydrinate may be used in conjunction with the Epley maneuver to reduce residual symptoms 4, 5.
• The Epley maneuver can be performed by general practitioners and emergency physicians, and its use can reduce resource utilization, ED length of stay, and the use of ineffective medications 5, 6, 3.
• Other treatments for BPPV may include rehabilitative exercises and physical maneuvers, although the Epley maneuver is considered the most effective treatment for posterior canal BPPV 2.

Effectiveness of Treatments

• Studies have shown that the Epley maneuver is associated with higher complete resolution of vertigo and higher conversion to negative Dix-Hallpike test compared to control treatments 2, 3.
• The use of betahistine and dimenhydrinate in conjunction with the Epley maneuver may provide additional benefits in reducing symptoms, although the evidence is not as strong as for the Epley maneuver alone 4, 5.
• The number-needed-to-treat for the Epley maneuver is 3, indicating that it is a highly effective treatment for BPPV 3.

Recommendations for Practice

• Emergency clinicians and general practitioners should become familiar with performing the Epley maneuver for BPPV, as it is a safe and effective treatment that can improve patient outcomes 6, 3.
• Further studies are needed on the implementation and education of the Epley maneuver in emergency departments and primary care settings 3.