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

From the Guidelines

The treatment for Benign Paroxysmal Positional Vertigo (BPPV) primarily involves canalith repositioning maneuvers, with the Epley maneuver being the most effective first-line treatment. For posterior canal BPPV, perform the Epley maneuver by having the patient sit upright, turn their head 45 degrees toward the affected side, quickly lie back with the head hanging 20 degrees off the edge of the table, wait 30 seconds, turn the head 90 degrees to the opposite side, wait another 30 seconds, then roll the body to that side and wait 30 seconds before slowly sitting up. This should be repeated 1-3 times per session until symptoms resolve, as recommended by the clinical practice guideline: benign paroxysmal positional vertigo (update) 1.

Key Points for Treatment

• The Epley maneuver is the most effective first-line treatment for posterior canal BPPV, with a strong recommendation for its use 1.
• The Semont maneuver is an alternative option for posterior canal BPPV.
• For horizontal canal BPPV, the BBQ roll or Gufoni maneuver is recommended, as outlined in the clinical practice guideline 1.
• Patients should be advised to avoid rapid head movements for 48 hours after treatment.
• Home exercises like the modified Epley (Brandt-Daroff exercises) can be taught for self-management.

Medication Use

• Vestibular suppressant medications like meclizine may provide temporary symptom relief but don't treat the underlying cause and should be used sparingly, as they are not routinely recommended for treatment of BPPV 1.
• These medications have the potential for significant harm, including drowsiness, cognitive deficits, and interference with driving or operating machinery, and are a significant independent risk factor for falls.

Evidence-Based Practice

The recommendation for the Epley maneuver as the first-line treatment is based on the highest quality evidence available, including a 2017 clinical practice guideline that provides a strong recommendation for its use 1. This guideline also recommends against the routine use of vestibular suppressant medications for BPPV treatment, citing their potential for harm and lack of effectiveness in treating the underlying cause of the condition 1.

From the Research

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

The primary treatment for BPPV involves physical therapy through maneuvers, with the goal of relocating free-floating particles from the affected semi-circular canals back into the utricle, thus relieving the symptoms of vertigo 2, 3, 4, 5, 6.

Canalith Repositioning Maneuvers

• The Epley maneuver is a widely used and effective treatment for posterior canal BPPV, with a high success rate in resolving vertigo symptoms 3, 5.
• Other canalith repositioning maneuvers, such as the Semont and Gufoni's maneuvers, are also effective and may be used depending on the clinician's preference or patient-specific factors 2.
• The choice of maneuver may depend on factors such as the patient's movement restrictions or failure of previous maneuvers 2.

Efficacy of Treatment

• Studies have shown that the Epley maneuver is a safe and effective treatment for posterior canal BPPV, with a significant reduction in vertigo symptoms and conversion of a positive Dix-Hallpike test to a negative test 3, 5.
• The efficacy of the Epley maneuver is comparable to other particle repositioning maneuvers, such as the Semont and Gans maneuvers 3.
• However, there is a high recurrence rate of BPPV after treatment, with approximately 36% of patients experiencing recurrence 3.

Other Treatment Options

• Surgical canal plugging may be indicated in selected cases of intractable severe BPPV 2.
• Chair-assisted treatment may be helpful in some cases, particularly if available 2.
• Medications such as benzodiazepines, antihistamines, and anticholinergic medications may be used to treat BPPV, but their efficacy is questionable and they are not recommended as a primary treatment 4.