What are the treatment options for Benign Paroxysmal Positional Vertigo (BPPV)?

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) are strongly recommended as the primary evidence-based treatment for BPPV, with 80-90% success rates after 1-2 treatments. 1

Diagnosis

Before treatment, proper diagnosis is essential:

• The Dix-Hallpike test is the gold standard for diagnosing BPPV
• A positive test shows vertigo with torsional, upbeating nystagmus when the patient moves from sitting to supine with head turned 45° and neck extended 20° 1

First-Line Treatment: Physical Maneuvers

Posterior Canal BPPV (most common)

• Epley maneuver - Level 1 evidence 1, 2
• Semont maneuver - Level 1 evidence, comparable efficacy to Epley 1, 2
• Success rate: 56% complete resolution of vertigo vs. 21% in control groups 3

Horizontal Canal BPPV

• Gufoni maneuver - Level 1 evidence 2, 4
• BBQ roll (Lempert 360° roll) - Level 1 evidence 4
  • Gufoni is often easier to perform as it only requires identifying the side of weaker nystagmus 4

Anterior Canal BPPV (rare)

• Deep head hanging maneuvers - Weaker evidence but may hasten recovery 2, 4

Self-Administered vs. Clinician-Guided Therapy

• Vestibular rehabilitation may be offered as either:
  • Self-administered therapy
  • Clinician-guided therapy
• Particularly beneficial for elderly patients
• May decrease recurrence rates 1

Pharmacological Treatment (Second-Line)

Medications should be used for short-term symptomatic relief only, as long-term use can delay vestibular compensation 1:

• Vestibular suppressants:

  • Antihistamines
  • Benzodiazepines (e.g., lorazepam)
  • Dopamine receptor antagonists (e.g., prochlorperazine, metoclopramide)

• For nausea management:

  • Prokinetic antiemetics (domperidone, metoclopramide)
  • 5-HT3 antagonists (e.g., ondansetron) 1

Treatment Considerations and Pitfalls

Common Pitfalls

1. Overuse of medications: Vestibular suppressants should only be used short-term as they can delay natural vestibular compensation 1
2. Missing multiple canal involvement: Some treatment failures are due to BPPV affecting multiple canals simultaneously 2
3. Failure to recognize central causes: Always rule out vertebrobasilar insufficiency, which can present with identical symptoms 1

Special Considerations

• High recurrence rate: BPPV has a 36% recurrence rate after treatment 3
• Comorbidities: Investigate for associated conditions like migraine or persistent postural perceptual dizziness in patients with unsatisfactory outcomes 2
• Risk factors for recurrence: Consider checking vitamin D levels, as low serum levels are associated with recurrence 2
• Physical limitations: Choose appropriate maneuvers based on patient's mobility and cervical spine range of motion 4

Surgical Options

• Canal plugging: Should be considered only for selected cases of intractable, severe BPPV affecting the same canal on the same side 2
• Surgery has a very minor role in BPPV management overall 4

Lifestyle Modifications and Prevention

• Regular physical activity (cardio-exercise for at least 30 minutes twice weekly)
• Home safety assessment to prevent falls
• Patient education about increased fall risk and potential recurrence 1

Treatment Algorithm

1. Confirm diagnosis with Dix-Hallpike test
2. Identify affected canal(s)
3. Perform appropriate repositioning maneuver based on canal involvement
4. If symptoms persist, repeat maneuver or try alternative maneuver
5. Use medications only for short-term symptomatic relief
6. Consider vestibular rehabilitation for persistent symptoms
7. Surgical options only for intractable cases