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

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) should be the first-line treatment for BPPV, with the specific maneuver determined by which semicircular canal is affected. 1

First-Line Treatments Based on Canal Involvement

Posterior Canal BPPV (Most Common)

• The Epley maneuver (canalith repositioning procedure) is the primary treatment with success rates of approximately 80% after 1-3 treatments 2, 1
• The procedure involves a series of head position changes:
  1. Patient seated with head turned 45° toward affected ear
  2. Rapidly laid back to supine head-hanging 20° position for 20-30 seconds
  3. Head turned 90° toward unaffected side for 20 seconds
  4. Head turned further 90° (patient moves to lateral position) for 20-30 seconds
  5. Patient returns to upright sitting position 2
• The Semont maneuver (liberatory maneuver) is an effective alternative with comparable efficacy 1, 3

Horizontal (Lateral) Canal BPPV

• The Barbecue Roll maneuver (Lempert maneuver) is the first-line treatment, involving rolling the patient 360° in sequential steps 2, 1
• The Gufoni maneuver is an easier alternative that only requires identifying the side with weaker nystagmus 3, 4

Treatment Efficacy and Expectations

• Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to observation alone (OR 6.52; 95% CI 4.17-10.20) 1
• A single CRP is more than 10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 1
• Success rates of 85% can be achieved with a single treatment session 5
• Patients may experience mild residual symptoms for a few days to weeks after successful treatment 1

Post-Treatment Recommendations

• Postprocedural restrictions are NOT recommended after CRP for posterior canal BPPV 2, 1
• Previous restrictions such as sleeping with head elevated or avoiding certain positions have not been shown to improve outcomes 2

Alternative and Adjunctive Treatments

Vestibular Rehabilitation

• May be offered as initial treatment or in conjunction with CRPs 2
• Includes habituation exercises, adaptation exercises for gaze stabilization, and balance training 2
• Particularly useful for patients with persistent symptoms or recurrent BPPV 2

Self-Administered Treatments

• Self-administered CRP can be taught to motivated patients with 64% improvement rates compared to 23% for self-administered Brandt-Daroff exercises 2, 1
• Home-based exercises may improve long-term outcomes and decrease recurrence rates 2

Medication Use

• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 1
• Medications may cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk (especially in elderly), and can interfere with central compensation 1
• Meclizine may be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) but does not treat the underlying condition 1, 6

Special Considerations

Treatment Failures

• If symptoms persist after initial treatment:
  • Reevaluate for persistent BPPV that may respond to additional repositioning maneuvers 1
  • Consider involvement of other semicircular canals 1
  • Assess for coexisting vestibular conditions 1
  • Repeat CRPs can achieve success rates of 90-98% for persistent BPPV 1
• For persistent cases not responding to standard CRP, adding mastoid vibration may improve outcomes 7
• Multiple CRPs in the same session may improve efficacy, with evidence suggesting an additional CRP after a negative Dix-Hallpike retest may reduce recurrence 8

Risk Factors for Recurrence

• Higher recurrence rates are observed in:
  • Elderly patients 5
  • Patients with history of head trauma 5
  • Patients with history of vestibular neuropathy 5
• These patients may require additional education and follow-up to minimize potential morbidity from falls 5

Contraindications and Precautions

• Patients with physical limitations may not be candidates for standard maneuvers, including those with:
  • Cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies
  • Morbid obesity, ankylosing spondylitis, low back dysfunction
  • Retinal detachment, spinal cord injuries 2
• These patients may need specialized examination tables or modified approaches 2, 1