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

Treatment Options for Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) are the first-line treatment for BPPV and should be used instead of medication therapy. 1

Diagnosis and Classification

• BPPV should be diagnosed when vertigo with characteristic nystagmus is provoked by the Dix-Hallpike maneuver (for posterior canal BPPV) or the supine roll test (for lateral canal BPPV) 1
• The most common form is posterior semicircular canal BPPV, followed by lateral (horizontal) canal BPPV 1

First-Line Treatment

Posterior Canal BPPV

• The Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice with success rates of 90-98% when performed correctly 1
• The procedure involves a specific sequence of head positions:
  1. Patient seated upright with head turned 45° toward affected ear
  2. Rapidly moved to supine position with head hanging 20° below horizontal
  3. Head turned 90° to unaffected side
  4. Head and body turned another 90° (face down position)
  5. Return to sitting position 1
• Alternative: Liberatory Maneuver (Semont maneuver) is equally effective 1

Lateral Canal BPPV

• Specific repositioning maneuvers such as the Gufoni maneuver or barbecue roll maneuver should be performed 1
• Success rates range from 86-100% with up to 4 treatments 1

Important Clinical Considerations

• Do not routinely prescribe vestibular suppressant medications (antihistamines like meclizine or benzodiazepines) for BPPV treatment 1
• Medications may be considered only for short-term management of severe nausea or vomiting, not as primary treatment 1
• Postprocedural restrictions after repositioning maneuvers are not necessary 1
• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 1

Alternative or Adjunctive Treatments

• Vestibular rehabilitation exercises may be offered as an option, either self-administered or clinician-guided 1
• Brandt-Daroff exercises are significantly less effective than CRP (25% vs 80.5% resolution at 7 days) but may be used in some cases 1
• Observation alone may be offered as initial management with assured follow-up 1

Management of Treatment Failures

• If symptoms persist after initial treatment, patients should be reevaluated for:
  1. Persistent BPPV requiring additional repositioning maneuvers
  2. Coexisting vestibular conditions
  3. Central nervous system disorders mimicking BPPV 1
• Canal conversion (e.g., posterior canal BPPV converting to lateral canal BPPV) occurs in approximately 6% of cases and requires appropriate repositioning for the newly affected canal 1
• For cases refractory to multiple CRPs, surgical options like canal plugging may be considered, with success rates >96% 1

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers 1
• Failing to reassess patients after initial treatment 1
• Missing canal conversions or multiple canal involvement 1, 2
• Overlooking central causes of vertigo that may mimic BPPV 1, 3
• Not recognizing post-treatment "otolithic crisis" with downbeating nystagmus, which occurs in about 19% of patients 2

By following these evidence-based recommendations, most patients with BPPV can achieve complete symptom resolution without medication or extensive testing.