What is the treatment for Benign Paroxysmal Vertigo (BPV)?

Treatment for Benign Paroxysmal Positional Vertigo (BPV)

The first-line treatment for Benign Paroxysmal Positional Vertigo (BPPV) is canalith repositioning procedures (CRPs), with the Epley maneuver being the most effective for posterior canal BPPV, achieving 80-90% success rates. 1

Diagnosis and Classification

Before initiating treatment, proper diagnosis is essential:

• Diagnostic Tests:

  • Dix-Hallpike test: Primary test for posterior canal BPPV (most common, 85-95% of cases) 2
  • Supine roll test: For lateral (horizontal) canal BPPV (5-15% of cases) 2

• Key Characteristics:

  • Sudden onset rotational vertigo
  • Symptoms provoked by position changes
  • Associated nausea and vomiting
  • Nystagmus that suppresses with visual fixation
  • Normal neurological exam 1

Treatment Algorithm

1. First-Line Treatment: Canalith Repositioning Procedures

• For Posterior Canal BPPV (85-95% of cases):

  • Epley maneuver: Most effective with 94% success rate 3
  • Semont (liberatory) maneuver: Alternative with comparable efficacy (98% success rate) 3

• For Lateral (Horizontal) Canal BPPV (5-15% of cases):

  • Log roll maneuvers: Highly effective (100% success rate in one study) 3
  • Gufoni's maneuver: Evidence-based alternative 4

• For Anterior Canal BPPV (rare):

  • Modified repositioning maneuvers, though evidence is weaker 4

2. Adjunctive Therapy

• Vestibular rehabilitation exercises:
  • Useful when CRPs fail
  • May decrease recurrence rates, especially in elderly patients 1
  • Redistribution exercises can complement repositioning maneuvers 3

3. Medication Management

• Important Caution: The American Academy of Otolaryngology-Head and Neck Surgery recommends AGAINST routine treatment with vestibular suppressant medications (including benzodiazepines) 1

• For symptom management only (not as definitive treatment):

  • Meclizine: FDA-approved for vertigo associated with vestibular system diseases
    • Dosage: 25-100 mg daily in divided doses 5
    • Caution: May cause drowsiness, dry mouth, and has potential anticholinergic effects 5
  • Prokinetic antiemetics (e.g., domperidone, metoclopramide): May help manage nausea without significantly interfering with vestibular compensation 1

Treatment Effectiveness and Follow-up

• Success Rates:

  • Epley maneuver: 94% of patients symptom-free or improved 3
  • Liberatory (Semont) maneuver: 98% success rate 3
  • Log roll maneuvers: 100% success rate 3
  • Average number of sessions needed: 3 for all techniques 3

• Recurrence Rate:

  • Approximately 16% at 6 months 3
  • Up to 36% long-term recurrence 6

Special Considerations

• Elderly Patients:

  • May require lower medication doses to avoid adverse effects
  • Higher risk of falls with untreated vestibular disorders
  • Vestibular rehabilitation particularly beneficial in reducing BPPV recurrence 1

• Treatment Failures:

  • Investigate for multiple canal involvement
  • Check for associated comorbidities (migraine, persistent postural perceptual dizziness)
  • Assess risk factors for recurrences (low vitamin D serum level) 4
  • Consider surgical canal plugging in selected same-canal, same-side intractable severe BPPV 4

Common Pitfalls to Avoid

1. Unnecessary imaging: No imaging is typically needed for uncomplicated BPPV with typical presentation 1

2. Overreliance on medications: Vestibular suppressants like meclizine provide symptomatic relief but do not treat the underlying cause and may delay vestibular compensation 1

3. Inadequate diagnosis: Failing to distinguish between posterior and horizontal canal BPPV can lead to using the wrong repositioning maneuver

4. Assuming benign etiology without adequate evaluation: Up to 11% of patients presenting with acute persistent vertigo may have an acute infarct 1

5. Neglecting patient education: Patients should be informed about safety concerns, fall prevention, potential for recurrence, and the importance of follow-up 1