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

From the Guidelines

Benign Paroxysmal Positional Vertigo (BPPV) is primarily treated with specific repositioning maneuvers, such as the Epley maneuver, which has been shown to be highly effective in resolving symptoms 1. The Epley maneuver involves a series of head position changes that should be performed by a healthcare provider initially, though patients can learn to do it at home.

• For posterior canal BPPV (most common type), the Epley maneuver involves:
  • Sitting upright
  • Turning the head 45 degrees toward the affected ear
  • Quickly lying back with the head hanging slightly off the edge of the bed
  • Turning the head 90 degrees to the opposite side
  • Rolling onto that side with the head turned 45 degrees downward
  • Finally returning to a sitting position This sequence should be repeated three times. The Semont and Brandt-Daroff exercises are alternative techniques that may be recommended. After treatment, patients should avoid sudden head movements and sleep semi-upright for 48 hours to prevent crystal displacement. Medication is generally not effective for BPPV itself but may help manage symptoms temporarily; options include meclizine (12.5-25mg every 4-6 hours), dimenhydrinate (50mg every 4-6 hours), or transdermal scopolamine patches for severe nausea, as noted in the guidelines 1. BPPV occurs when calcium carbonate crystals become dislodged from the utricle and move into the semicircular canals, causing inappropriate signals about head movement that result in vertigo when the head changes position, as explained in the clinical practice guideline 1. Vestibular rehabilitation may also be offered as an option for the treatment of BPPV, as stated in the executive summary of the clinical practice guideline 1. It is essential to diagnose BPPV accurately and differentiate it from other causes of imbalance, dizziness, and vertigo, following the recommendations outlined in the guideline 1. The Gufoni maneuver is another technique that can be used for the treatment of lateral semicircular canal BPPV, as described in the guideline 1. Overall, the treatment of BPPV should focus on relieving symptoms and improving quality of life, with the Epley maneuver being the most effective treatment option, as supported by the evidence 1.

From the Research

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

• The primary evidence-based treatment strategy for BPPV is physical therapy through maneuvers, including the Epley, Semont, and Gufoni's maneuvers 2, 3, 4, 5, 6.
• These maneuvers are considered level 1 evidence treatment for BPPV, with comparable efficacy, and the choice of maneuver depends on the clinician's preferences, failure of previous maneuvers, or patient movement restrictions 2.
• The Epley maneuver is a commonly used and effective treatment for posterior canal BPPV, with studies showing a statistically significant effect in favor of the Epley maneuver over controls 4, 5.
• Other treatment options, such as the Semont maneuver and Brandt and Daroff exercises, may also be effective, but with varying cure rates and relapse rates 6.
• In some cases, chair-assisted treatment or surgical canal plugging may be necessary for intractable or severe BPPV 2.
• Postural restrictions are not necessary after canalith repositioning maneuver (CRM) treatment, and medications are not as effective as CRM 3.

Considerations for Treatment

• The treatment approach may vary depending on the specific type of BPPV, such as anterior canal or apogeotropic posterior canal BPPV, which have weaker evidence of efficacy for maneuvers 2.
• Patients with unsatisfactory outcomes or recurrences may need to be investigated for underlying comorbidities, such as migraine or persistent postural perceptual dizziness, or risk factors for recurrences, such as low vitamin D serum level 2.
• Future research should aim to identify the optimum maneuvers for variants of BPPV and to improve treatment outcomes for patients with this condition 2.