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

First-Line Treatment for Benign Paroxysmal Positional Vertigo (BPPV)

Canalith Repositioning Procedures (CRPs), particularly the Epley maneuver, are the first-line treatment for BPPV with success rates of 80-90% after 1-3 treatments. 1

Diagnosis and Assessment

Before treatment, proper diagnosis is essential:

• The Dix-Hallpike test is the gold standard for diagnosing posterior canal BPPV (the most common type)
• The supine roll test is used for lateral (horizontal) canal BPPV 1
• Unnecessary imaging (CT or MRI) is not needed to diagnose BPPV 1

Treatment Algorithm

1. Posterior Canal BPPV (Most Common)

• First-line: Epley Maneuver (Canalith Repositioning Procedure) 2, 1
  • Success rate: 80-90% after 1-3 treatments 1
  • 91% of posterior canal BPPV cases can be effectively treated in 2 maneuvers or less 3
  • Procedure steps:
    1. Patient seated upright, head turned 45° toward affected ear
    2. Rapidly move patient to supine head-hanging position for 20-30 seconds
    3. Turn head 90° toward unaffected side, hold 20 seconds
    4. Turn head and body another 90° (face-down position), hold 20-30 seconds
    5. Return patient to upright sitting position 2

2. Horizontal Canal BPPV

• First-line: Barbecue Roll or Gufoni Maneuver 1
  • 88% of horizontal canal BPPV cases can be effectively treated with 2 treatments 3

3. Multiple or Bilateral Canal Involvement

• May require more treatments and specialized approaches 3
• Consider referral to vestibular specialist if not responding to initial treatment

Important Clinical Considerations

1. Repeated testing and treatment within the same session is safe and effective with low risk of canal conversion 3

2. Common misconceptions to avoid:

   • Vertigo and nystagmus throughout the Epley maneuver is NOT indicative of treatment success 3
   • Medications like meclizine are NOT recommended as first-line treatment 4

3. Potential adverse effects:

   • Mild and self-limiting in about 12% of patients 2
   • Nausea during repositioning (16.7-32%) 5
   • Post-treatment down-beating nystagmus and vertigo ("otolithic crisis") in 19% of patients 3
   • Some patients with cervical spine problems may not tolerate the maneuvers 5

4. Follow-up:

   • Reassess within 1 month after initial treatment to confirm symptom resolution 1
   • Be aware of high recurrence rate (16-36%) 5, 6

Alternative Approaches

If CRP cannot be performed or is unsuccessful:

• Semont maneuver (liberatory maneuver) - comparable effectiveness to Epley 5
• Gans maneuver - comparable effectiveness to Epley 5
• Brandt-Daroff exercises - less effective than Epley but may be used as home therapy 5
• Vestibular rehabilitation - particularly beneficial for elderly patients 1

Patient Education

• Inform patients about possible recurrence and recognition signs 1
• Advise about increased fall risk, especially in elderly patients 1
• Educate about the importance of follow-up and when to seek care if symptoms return 1

The evidence strongly supports canalith repositioning procedures as the most effective first-line treatment for BPPV, with multiple high-quality guidelines and studies demonstrating their efficacy over medication or observation alone.