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

Treatment for Benign Paroxysmal Positional Vertigo (BPPV)

The primary evidence-based treatment for BPPV is canalith repositioning procedures (CRPs), particularly the Epley maneuver for posterior canal BPPV, with a success rate of 80-90% after 1-2 treatments. 1

Diagnosis and Canal Identification

Before treatment, proper diagnosis and canal identification are essential:

• Dix-Hallpike test: Gold standard for diagnosing posterior canal BPPV 1
• Supine roll test: For diagnosing lateral (horizontal) canal BPPV 1

Treatment Algorithm

1. First-line treatment: Canalith Repositioning Procedures

   • Posterior canal BPPV (most common, ~80% of cases):
     • Epley maneuver or Semont maneuver 1, 2
   • Horizontal canal BPPV:
     • Gufoni maneuver or Barbecue roll (Lempert 360° roll) 1, 3
   • Anterior canal BPPV (rare):
     • Deep head hanging maneuvers 3

2. Medication (adjunctive only):

   • Meclizine: 25-100 mg daily in divided doses for symptomatic relief of vertigo 4
   • Important caveat: Medications do not treat the underlying cause and should not replace repositioning maneuvers 1, 5
   • Warning: May cause drowsiness; use caution when driving or operating machinery 4

3. Follow-up and Reassessment:

   • Reassess within 1 month after initial treatment 1
   • If symptoms persist, consider:
     • Incorrect diagnosis
     • Multiple canal involvement
     • Underlying peripheral vestibular or CNS disorders 1

Efficacy of Repositioning Maneuvers

• Epley maneuver is significantly more effective than sham procedures or no treatment (OR 4.42) 6
• Complete resolution of vertigo increases from 21% to 56% with Epley maneuver 6
• Epley and Semont maneuvers have comparable efficacy for posterior canal BPPV 3
• Gufoni maneuver is easier to perform than BBQ roll for horizontal canal BPPV 3

Common Pitfalls to Avoid

1. Unnecessary imaging: CT or MRI is not needed to diagnose BPPV 1
2. Over-reliance on medications: Vestibular suppressants like meclizine may temporarily relieve symptoms but do not treat the underlying cause 5
3. Missing multiple canal involvement: Can lead to persistent symptoms 1
4. Inadequate follow-up: Important to confirm symptom resolution 1

Special Considerations

• Elderly patients: May benefit more from vestibular rehabilitation in addition to CRPs 1
• Patients with mobility issues: May require assistance or modified techniques 1
• Recurrence risk: Approximately 15% per year; patients should be educated about recognizing recurrent symptoms 1
• Fall risk: Patients, especially elderly, should be counseled about increased fall risk 1

When to Consider Alternative Diagnoses

If BPPV symptoms are atypical or refractory to treatment, consider:

• Neurological examination
• CNS testing
• MRI of brain and posterior fossa 1

Canalith repositioning procedures are highly effective, inexpensive, and easy to apply, making them the definitive first-line treatment for BPPV, with medications serving only as adjunctive therapy for symptom management.