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

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

Clinicians should treat patients with posterior canal BPPV with a canalith repositioning procedure (CRP) as the first-line treatment. 1

Diagnosis Before Treatment

Before initiating treatment, proper diagnosis is essential:

• The Dix-Hallpike test is the gold standard for diagnosing posterior canal BPPV
  • Positive when vertigo with torsional, upbeating nystagmus occurs when the patient moves from sitting to supine with head turned 45° and neck extended 20° 2
• For horizontal canal BPPV, a supine roll test should be performed if the Dix-Hallpike test shows horizontal or no nystagmus 1

First-Line Treatment Options

For Posterior Canal BPPV (most common type):

1. Epley Maneuver (Canalith Repositioning Procedure)

   • Success rate of 80-90% with 1-2 treatments 2
   • Highly effective, inexpensive, and easy to apply 3

2. Semont Maneuver

   • Comparable efficacy to the Epley maneuver 3
   • Choice between Epley and Semont often based on clinician preference and patient factors

For Horizontal Canal BPPV:

1. Gufoni Maneuver

   • Easier to perform as it only requires identification of the side with weaker nystagmus 3

2. BBQ Roll (Lempert 360° Roll)

   • Effective alternative for horizontal canal BPPV 3

Treatment Protocol

• Initial treatment session:

  • Single CRP may resolve symptoms in 85% of patients 4
  • Repeated CRPs in the same session can be beneficial 5
  • Follow-up assessment within 48 hours to 7 days 4

• Only 2% of patients require more than 3 CRP sessions 4

Important Considerations

• Avoid vestibular suppressant medications:

  • Clinicians should not routinely treat BPPV with antihistamines or benzodiazepines 1
  • These medications may temporarily relieve symptoms but do not treat the underlying condition

• No postprocedural restrictions needed:

  • Postural restrictions after CRP are not recommended 1

• Alternative management options:

  • Observation with follow-up may be offered as initial management 1
  • Vestibular rehabilitation (self-administered or clinician-guided) may be offered as an adjunct treatment 1, 2

Special Considerations

• Higher recurrence rates are observed in:

  • Elderly patients
  • Patients with history of head trauma
  • Patients with history of vestibular neuropathy 4

• Post-treatment complications:

  • About 19% of patients may experience post-treatment down-beating nystagmus and vertigo ("otolithic crisis") after the first or second consecutive Epley maneuver 6
  • Clinicians should be vigilant about this possibility to ensure patient safety and prevent falls

Follow-up

• Follow-up within 1 month is recommended to confirm resolution 2
• Long-term monitoring may be necessary for patients at higher risk of recurrence
• Patient education about possible recurrence and recognition signs is important 2