What is the management of Benign Paroxysmal Positional Vertigo (BPPV)?

Management of Benign Paroxysmal Positional Vertigo (BPPV)

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

Diagnosis

• BPPV is diagnosed through specific bedside tests 1:
  • Dix-Hallpike test for posterior canal BPPV (most common type) - vertigo with torsional, upbeating nystagmus confirms diagnosis 2
  • Supine roll test for horizontal canal BPPV 2
• Normal medical imaging and laboratory testing cannot confirm BPPV and should not be routinely ordered unless the diagnosis is uncertain or there are additional symptoms unrelated to BPPV 2, 1

Treatment Algorithm Based on Canal Involvement

Posterior Canal BPPV (most common)

• First-line treatment: Epley maneuver (CRP) 2, 1
  • Success rates: 80.5% negative Dix-Hallpike by day 7 1
  • Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls 1, 3
• Alternative: Semont maneuver (Liberatory Maneuver) 1, 4
  • Comparable efficacy to Epley maneuver 4, 5

Horizontal Canal BPPV

• First-line treatment: Barbecue Roll Maneuver (Lempert maneuver) or Gufoni maneuver 1, 5
  • Gufoni maneuver may be easier to perform as it only requires identifying the side of weaker nystagmus 5

Anterior Canal BPPV (rare)

• Treatment: Deep head hanging maneuvers 5
  • Generally short-lived and may resolve spontaneously 5

Post-Treatment Considerations

• Postprocedural restrictions are NOT recommended after CRP for posterior canal BPPV 2, 1
  • Strong recommendation against restrictions based on RCTs 2
• Patients may experience mild residual symptoms for a few days to weeks after successful treatment 1
• Reassess patients within 1 month after treatment to confirm symptom resolution 2

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients 2, 1
  • More effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 2, 1
• A single CRP is >10 times more effective than a week of Brandt-Daroff exercises 1, 3

Medication Use

• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 2, 1
  • Can cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 1
  • May interfere with central compensation and decrease diagnostic sensitivity during Dix-Hallpike maneuvers 1
• May be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 1

Management of Treatment Failures

• If symptoms persist after initial treatment, patients should be reevaluated for 1:
  • Persistent BPPV that may respond to additional repositioning maneuvers
  • Involvement of other semicircular canals
  • Coexisting vestibular conditions
  • Possible CNS disorders
• Repeat CRPs can achieve success rates of 90-98% for persistent BPPV 1

Observation as Initial Management

• Observation with follow-up may be offered as initial management 2
  • Spontaneous resolution occurs in approximately 20% of patients by 1 month and up to 50% at 3 months 2
• However, this approach may not be suitable for older patients, those with preexisting balance disorders, or individuals at high risk for falls 2

Common Pitfalls and Caveats

• 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 may need specialized examination tables or modified approaches 1
• BPPV has a high recurrence rate (36%) after treatment 3
• Untreated BPPV increases risk of falls, especially in elderly patients 2