What are the first line treatment maneuvers for positional vertigo?

First-Line Treatment Maneuvers for Positional Vertigo

The Canalith Repositioning Procedure (CRP), commonly known as the Epley maneuver, should be the first-line treatment for posterior canal benign paroxysmal positional vertigo (BPPV), with the Semont maneuver (liberatory maneuver) as an alternative option. 1

Posterior Canal BPPV Treatment (Most Common Type)

Epley Maneuver (CRP) - Primary Recommendation

The Epley maneuver involves a specific sequence of head position changes designed to move free-floating particles from the posterior semicircular canal back into the vestibule:

1. Position patient upright with head turned 45° toward the affected ear
2. Rapidly move patient to supine position with head hanging 20° below horizontal for 20-30 seconds
3. Turn head 90° toward unaffected side, hold for 20 seconds
4. Turn head and body another 90° (face down position), hold for 20-30 seconds
5. Return patient to upright sitting position 1

Semont Maneuver (Liberatory Maneuver) - Alternative Option

The Semont maneuver is equally effective and involves:

1. Start with patient sitting, head turned away from affected side
2. Quickly move patient to side-lying position toward affected side with head turned up
3. After nystagmus ceases (wait at least 20 seconds), quickly move patient through sitting position to opposite side-lying position with head facing down
4. Hold for 30 seconds, then slowly return to sitting position 1

Lateral Canal BPPV Treatment

For Geotropic Type:

• Gufoni maneuver or barbecue roll maneuver is recommended
• Gufoni steps:
  1. Move from sitting to side-lying on unaffected side for 30 seconds
  2. Turn head 45°-60° toward floor, hold 1-2 minutes
  3. Return to sitting with head toward unaffected shoulder 1

For Apogeotropic Type:

• Modified Gufoni maneuver:
  1. Move from sitting to side-lying on affected side for 30 seconds
  2. Turn head 45°-60° toward floor, hold 1-2 minutes
  3. Return to sitting with head toward unaffected shoulder 1

Treatment Efficacy and Approach

• Success rates: 80-90% after 1-2 treatments of CRP for posterior canal BPPV 2
• Multiple treatments may be necessary:
  • 32-90% resolve after first treatment
  • 40-100% after second treatment
  • 67-98% after third treatment
  • 87-100% after fourth treatment 1, 3

Important Clinical Considerations

No Postprocedural Restrictions Needed

• Strong recommendation against postprocedural restrictions after CRP for posterior canal BPPV 1
• Evidence shows no benefit to head position restrictions after treatment

Self-Administered Options

• Self-administered CRP (95% success) is more effective than self-administered Semont (58% success) 1
• Self-administered CRP is more effective (64% improvement) than Brandt-Daroff exercises (23% improvement) 1

Cautions and Complications

• Mild adverse effects occur in about 12% of patients (nausea, vomiting, temporary imbalance) 1
• Canal conversion (switching to lateral canal BPPV) occurs in 6-7% of cases 1
• Use caution in patients with cervical spine problems, certain vascular conditions, or retinal detachment 1, 4

Medication Role

• Vestibular suppressants like meclizine (25-100 mg daily in divided doses) should be used only for short-term symptomatic relief 2, 5
• Long-term medication use can delay vestibular compensation 2
• Medications should not replace repositioning maneuvers as primary treatment 2

Follow-up Management

• If symptoms persist after initial treatment, repeat the appropriate repositioning maneuver
• Consider vestibular function testing for patients with:
  • Atypical nystagmus
  • Suspected additional vestibular pathology
  • Failed response to CRP
  • Frequent recurrences 1

The evidence strongly supports repositioning maneuvers as the definitive first-line treatment for BPPV, addressing the underlying cause rather than just managing symptoms with medication.