What is the management of benign paroxysmal positional vertigo (BPPV)?

Management of Benign Paroxysmal Positional Vertigo (BPPV)

The most effective management of BPPV is to diagnose with the Dix-Hallpike test and treat with a canalith repositioning procedure (CRP), such as the Epley maneuver, which has a success rate of 80-90% for posterior canal BPPV. 1, 2

Diagnosis

Clinical Presentation

• Brief episodes of vertigo triggered by changes in head position
• Symptoms typically last less than one minute
• May be accompanied by nausea
• No hearing loss or other neurological symptoms

Diagnostic Testing

• Dix-Hallpike maneuver: Gold standard for diagnosing posterior canal BPPV 2

  • Performed by bringing the patient from upright to supine position with head turned 45° to one side and neck extended 20° with the affected ear down
  • Positive test: Vertigo with characteristic torsional, upbeating nystagmus

• Supine roll test: For lateral (horizontal) canal BPPV 2

  • Performed when Dix-Hallpike is negative but history suggests BPPV
  • Patient lies supine with head turned 90° to each side
  • Positive test: Horizontal nystagmus

• Avoid unnecessary testing 2

  • Radiographic imaging is NOT recommended unless diagnosis is uncertain or additional symptoms suggest other pathology
  • Vestibular testing is NOT recommended for typical BPPV

Treatment

First-Line Treatment

• Canalith Repositioning Procedures (CRPs) 2, 1, 3
  • For posterior canal BPPV: Epley maneuver
  • For horizontal canal BPPV: Barbecue roll maneuver or Gufoni maneuver
  • Success rate: 80-90% with 1-2 treatments 4
  • Repeated testing and treatment within the same session is safe and effective 4

Important Treatment Considerations

• Nystagmus or vertigo during the Epley maneuver is NOT indicative of treatment success 4
• Post-treatment downbeating nystagmus and vertigo ("otolithic crisis") may occur in approximately 19% of patients 4
• No postprocedural postural restrictions are necessary after CRP 2

Alternative Treatments

• Vestibular rehabilitation: May be offered as self-administered or clinician-guided therapy 2, 1

  • Particularly beneficial for elderly patients
  • May decrease recurrence rates

• Observation with follow-up: May be offered as initial management 2

  • BPPV can resolve spontaneously in some cases

Treatments to AVOID

• Vestibular suppressant medications (antihistamines, benzodiazepines) 2, 1, 5
  • NOT recommended for routine treatment
  • May interfere with vestibular compensation
  • May be used temporarily for short-term symptom relief while awaiting definitive treatment
  • Have side effects but little therapeutic effect

Follow-up and Recurrence

• Reassess patients within 1 month after initial treatment to confirm symptom resolution 2
• Evaluate treatment failures for:
  • Persistent BPPV
  • Incorrect diagnosis
  • Underlying peripheral vestibular or CNS disorders
• Recurrence rate is approximately 36% 3
• Counsel patients about:
  • Increased fall risk, especially in elderly
  • Possibility of recurrence
  • Signs of recurrence
  • Importance of follow-up

Special Considerations

• Elderly patients:

  • Higher risk of falls
  • May benefit more from vestibular rehabilitation
  • Require lower medication doses if vestibular suppressants are used temporarily

• Patients with mobility issues:

  • Assess for home safety
  • Consider activity restrictions until symptoms resolve

Treatment Algorithm

1. Diagnose BPPV type using Dix-Hallpike (posterior canal) or supine roll test (horizontal canal)
2. Perform appropriate CRP based on canal involvement (Epley for posterior canal)
3. Repeat CRP if needed during same session
4. Reassess within 1 month
5. For persistent symptoms, re-evaluate diagnosis or consider vestibular rehabilitation
6. Avoid vestibular suppressant medications except for temporary symptom relief

By following this evidence-based approach, clinicians can effectively manage BPPV, reduce unnecessary testing and medications, and improve patient outcomes.