What maneuver helps Benign Paroxysmal Positional Vertigo (BPPV)?

Maneuvers for Benign Paroxysmal Positional Vertigo (BPPV)

The Epley maneuver (canalith repositioning procedure) is strongly recommended as the primary evidence-based treatment for posterior canal BPPV, with 80-90% success rates after 1-2 treatments. 1

Diagnosis and Assessment

• Dix-Hallpike test: Gold standard for diagnosing posterior canal BPPV
  • Positive test: Vertigo with torsional, upbeating nystagmus when patient moves from sitting to supine with head turned 45° and neck extended 20° 1
  • Essential to perform before treatment to confirm diagnosis and identify affected canal

Treatment Options by Canal Type

Posterior Canal BPPV (Most Common)

1. First-line: Epley Maneuver

   • Success rate: 80-90% after 1-2 treatments 1
   • Evidence shows patients treated with Epley are 4.42 times more likely to have complete resolution of vertigo compared to sham or no treatment 2
   • Conversion from positive to negative Dix-Hallpike test is 9.62 times more likely with Epley 2
   • Number needed to treat: 3 3

2. Alternative: Semont Maneuver

   • Comparable efficacy to Epley 4
   • May require fewer repeat maneuvers for complete resolution 5
   • Advantages: Easier to perform, fewer position changes, takes less time, no post-maneuver mobility restrictions 5
   • Particularly beneficial for older patients and those with spinal problems 5

3. Other Options:

   • Gans maneuver: Similar efficacy to Epley 2
   • Brandt-Daroff exercises: Less effective than Epley (single Epley treatment is 12.38 times more effective than a week of Brandt-Daroff exercises) 2

Horizontal Canal BPPV

• Gufoni maneuver: Level 1 evidence treatment 4
• 88% of cases effectively managed with 2 treatments 6

Clinical Pearls and Considerations

• Multiple treatments may be necessary:

  • Repeated testing and treatment within the same session is safe and effective 6
  • 91% of posterior canal BPPV cases resolve with 2 or fewer maneuvers 6
  • More treatments may be needed for:
    • Bilateral posterior canal involvement
    • Multiple canal involvement
    • Canal conversions 6

• Important observations during treatment:

  • Presence or absence of nystagmus and symptoms during the Epley maneuver does not predict treatment success 6
  • Post-treatment downbeating nystagmus and vertigo ("otolithic crisis") may occur in 19% of patients after first or second consecutive Epley maneuver 6

• Recurrence considerations:

  • High recurrence rate (36%) after treatment 2
  • Patients with unsatisfactory outcomes should be investigated for:
    • Recurrences
    • Multiple canal involvement
    • Associated comorbidities (migraine, persistent postural perceptual dizziness)
    • Risk factors for recurrences (low vitamin D serum level) 4

Potential Adverse Effects

• Generally safe with no serious adverse effects reported 2
• Nausea during repositioning maneuvers: 16.7% to 32% of patients 2
• Some patients with cervical spine problems may not tolerate the maneuvers 2
• Monitor for post-treatment otolithic crisis to ensure patient safety and prevent falls 6

Follow-up

• Reassess with Dix-Hallpike test after treatment
• Consider vestibular rehabilitation, particularly beneficial for elderly patients 1
• Vestibular rehabilitation may decrease recurrence rates 1