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

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) are the first-line treatment for BPPV, with the Epley maneuver being the treatment of choice for posterior canal BPPV, achieving success rates of 90-98% when performed correctly. 1, 2

Diagnosis and Classification

• BPPV is diagnosed when vertigo with characteristic nystagmus is provoked by the Dix-Hallpike maneuver (for posterior canal BPPV) or the supine roll test (for horizontal canal BPPV) 3, 2
• Posterior canal BPPV is most common (85-95% of cases), followed by horizontal canal BPPV (5-15% of cases) 3

Treatment Based on Canal Involvement

Posterior Canal BPPV (Most Common)

• Epley maneuver is the first-line treatment with strong evidence, involving these steps 1, 2:

  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

• Semont maneuver (Liberatory Maneuver) is an effective alternative with comparable efficacy 1, 4

• 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, 4

Horizontal Canal BPPV

• Barbecue Roll Maneuver (Lempert maneuver) is a first-line treatment, involving rolling the patient 360 degrees in sequential steps 1, 5
• Gufoni maneuver is an effective alternative that may be easier to perform as it only requires identifying the side of weaker nystagmus 5

Treatment Efficacy and Follow-up

• Success rates for CRP (Epley) for posterior canal BPPV are approximately 80.5% by day 7 1
• Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls 1
• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 2
• Repeated testing and treatment within the same session is safe and effective with low risk of canal conversion 6

Important Clinical Considerations

• Postprocedural restrictions after CRP for posterior canal BPPV are NOT recommended 3, 1
• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 3, 1, 2
• Medications may be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) 1, 2
• Approximately 19% of patients may experience post-treatment down-beating nystagmus and vertigo ("otolithic crisis") after the first or second consecutive Epley maneuver 6

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients and appears more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 1

Management of Treatment Failures

• If symptoms persist after initial treatment, patients should be reevaluated for 1, 2:

  1. Persistent BPPV that may respond to additional repositioning maneuvers
  2. Involvement of other semicircular canals
  3. Coexisting vestibular conditions
  4. Possible CNS disorders

• Canal conversion occurs in approximately 6-7% of cases during treatment and requires appropriate repositioning for the newly affected canal 1, 2

• Repeat CRPs can achieve success rates of 90-98% for persistent BPPV 1

• For cases refractory to multiple CRPs, surgical options like canal plugging may be considered in selected same-canal, same-side intractable severe BPPV 2, 7

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers 2, 8
• Ordering unnecessary imaging studies such as brain CT or MRI 3, 8
• Failing to reassess patients after initial treatment 2
• Missing canal conversions or multiple canal involvement 1, 2