What is the recommended maneuver for treating benign positional vertigo (BPV)?

Recommended Maneuvers for Benign Positional Vertigo

The canalith repositioning procedure (CRP), specifically the Epley maneuver, is the recommended first-line treatment for posterior canal BPPV, with success rates of approximately 80% after just 1-3 treatments. 1

Diagnosis and Canal Identification

Before performing any repositioning maneuver, proper diagnosis of the affected canal is essential:

• Posterior canal BPPV (most common, 80-90% of cases): Diagnosed using the Dix-Hallpike test, which provokes vertigo with torsional, upbeating nystagmus 2
• Horizontal canal BPPV (10-15% of cases): Diagnosed using the supine roll test, which may show either geotropic (nystagmus beating toward the ground) or apogeotropic (nystagmus beating away from the ground) patterns 2
• Anterior canal BPPV (rare): Limited evidence for specific diagnostic criteria 1

Treatment by Canal Type

For Posterior Canal BPPV:

• First-line: Epley Maneuver (CRP) 2, 1

  1. Patient sits upright with head turned 45° toward affected ear
  2. Patient is rapidly laid back to supine head-hanging 20° position for 20-30 seconds
  3. Head is turned 90° toward unaffected side and held for 20 seconds
  4. Head and body are turned another 90° (face down position) for 20-30 seconds
  5. Patient returns to sitting position

• Alternative: Semont Maneuver (Liberatory Maneuver) 1, 3

  • Equally effective as the Epley maneuver but involves more rapid movements

For Horizontal Canal BPPV:

• For geotropic variant: 2

  • Gufoni Maneuver:
    1. Patient moves from sitting to side-lying position on the unaffected side for 30 seconds
    2. Head is quickly turned 45°-60° toward the ground and held for 1-2 minutes
    3. Patient returns to sitting with head toward the opposite shoulder

• For apogeotropic variant: 2

  • Modified Gufoni Maneuver:
    1. Patient moves from sitting to side-lying position on the affected side for 30 seconds
    2. Head is quickly turned 45°-60° toward the ground and held for 1-2 minutes
    3. Patient returns to sitting with head toward the opposite shoulder

• Alternative: Barbecue Roll (Lempert) Maneuver 1, 3

  • Involves rolling the patient 360° in sequential 90° steps

Treatment Efficacy and Follow-up

• Single CRP treatment success rates: 72-80.5% resolution after first treatment 1, 4
• Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls 1
• If symptoms persist, repeat maneuvers can achieve success rates of 90-98% 1
• Second session treatment success: Additional 16.2% of patients 4
• Third or fourth sessions may be required in approximately 4.4% of cases 4

Important Clinical Considerations

• No postprocedural restrictions are recommended after CRP for posterior canal BPPV 2, 1
• Self-administered CRP can be taught to motivated patients and is 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
• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 1
• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment 1

When Treatment Fails

• Reevaluate for:
  • Persistent BPPV that may respond to additional repositioning maneuvers 1
  • Involvement of other semicircular canals 1
  • Coexisting vestibular conditions 1
  • Possible CNS disorders 1

Special Considerations

• Patients with physical limitations may need modified approaches 1
• Patients with severe disabling symptoms, history of falls, or difficulty moving should be referred to specialists 1
• Surgical canal plugging should only be considered in selected same-canal, same-side intractable severe BPPV cases 5