What is the treatment for benign paroxysmal positional vertigo (BPPV)?

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

The most effective first-line treatment for BPPV is canalith repositioning procedures (CRPs), specifically the Epley maneuver for posterior canal BPPV, which has a success rate of approximately 80% with just 1-3 treatments. 1

Diagnosis and Canal Identification

• BPPV is diagnosed through bedside testing, primarily the Dix-Hallpike test for posterior canal BPPV (most common) and the supine roll test for horizontal canal BPPV 1
• Posterior semicircular canal involvement is most common (73.5%), followed by horizontal semicircular canal (22.5%), and rarely anterior canal or multicanal involvement 2
• Normal medical imaging (scans, x-rays) and laboratory testing cannot confirm BPPV 1

Treatment Based on Canal Involvement

Posterior Canal BPPV (Most Common)

• Canalith Repositioning Procedure (Epley maneuver) - First-line treatment with strong evidence 1

  • Step 1: Patient seated upright, head turned 45° toward affected ear
  • Step 2: Rapidly move patient to supine head-hanging position (20°), maintain for 20-30 seconds
  • Step 3: Turn head 90° toward unaffected side, hold for 20 seconds
  • Step 4: Turn head and body another 90° (face-down position), hold for 20-30 seconds
  • Step 5: Return patient to upright sitting position 1

• Liberatory Maneuver (Semont maneuver) - Alternative with good evidence 1

  • Step 1: Patient seated upright, head turned 45° away from affected ear
  • Step 2: Quickly move patient to side-lying position on affected side, hold for 30 seconds
  • Step 3: Rapidly move patient to opposite side-lying position without changing head position relative to shoulder, hold for 30 seconds
  • Step 4: Return patient to upright position 1

Horizontal Canal BPPV

• Barbecue Roll Maneuver (Lempert maneuver) - First-line for horizontal canal BPPV 1

  • Involves rolling the patient 360 degrees in sequential steps 1

• Gufoni Maneuver - Alternative for horizontal canal BPPV 1, 3

  • Easier to perform as it only requires identifying the side of weaker nystagmus 3

Treatment Efficacy

• Success rates for CRP (Epley) for posterior canal BPPV: 80.5% negative Dix-Hallpike by day 7 1
• Success rates for repositioning maneuvers range from 75% for multicanal to 95.8% for posterior canal BPPV 2
• Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20) 1
• A single CRP is >10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 1

Treatment Protocol

• Repeated maneuvers during a single treatment session appear more effective than a single maneuver 4
• For posterior canal BPPV, 91% of cases can be effectively treated with 2 maneuvers or less 5
• For horizontal canal BPPV, 88% of cases can be effectively treated with 2 treatments 5
• Multiple canal involvement or canal conversions may require more treatments 5

Post-Treatment Considerations

• Postprocedural restrictions are NOT recommended after CRP for posterior canal BPPV 1
• Patients may experience mild residual symptoms for a few days to weeks after successful treatment 1
• About 19% of patients may experience post-treatment down-beating nystagmus and vertigo ("otolithic crisis") after the first or second consecutive Epley maneuver 5

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients 1
• Self-administered CRP appears more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 1
• Self-treatment may be particularly useful for patients with frequent recurrences 4

When to Refer

• Patients who fail to respond to repeated maneuvers should be referred to specialized care 2
• Suspected horizontal or anterior canal BPPV should be examined by a specialist to rule out other neurological conditions 4
• Patients with severe disabling symptoms, history of falls, or difficulty moving should be referred to a healthcare professional experienced in performing repositioning maneuvers 1

Pitfalls and Caveats

• Vertigo and nystagmus throughout the Epley maneuver is not necessarily indicative of treatment success 5
• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment 1
• Patients with physical limitations (cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, etc.) may need specialized examination tables or modified approaches 1
• Clinicians must remain vigilant about post-treatment vertigo to prevent possible falls 5