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

Recommended Maneuver for Benign Positional Vertigo

For benign paroxysmal positional vertigo (BPPV), the Epley maneuver is strongly recommended as the first-line treatment for posterior canal BPPV, which accounts for 80-90% of cases. 1, 2

Diagnosis and Canal Identification

• BPPV is diagnosed through bedside testing, primarily the Dix-Hallpike test for posterior canal BPPV (80-90% of cases) and the supine roll test for horizontal canal BPPV (10-15% of cases) 2
• Posterior canal BPPV is diagnosed when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 1
• Normal medical imaging and laboratory testing cannot confirm BPPV and should not be routinely ordered 2

Treatment Based on Canal Type

Posterior Canal BPPV (Most Common)

• Epley maneuver (first-line treatment):

  • Success rate of approximately 80% with just 1-3 treatments 2
  • Involves a series of specific head and body movements: patient sitting upright with head turned 45° toward affected ear, then rapidly laying back to a supine head-hanging position for 20-30 seconds, followed by sequential head and body turns 2, 3
  • Patients treated with the Epley maneuver have 6.5 times greater chance of symptom improvement compared to controls 2

• Semont maneuver (alternative treatment):

  • Comparable efficacy to the Epley maneuver 4, 5
  • May be preferred for patients with certain neck mobility issues 5

Horizontal Canal BPPV

• Barbecue Roll Maneuver (Lempert maneuver) for geotropic variant 2
• Gufoni Maneuver for both geotropic and apogeotropic variants 2, 4
  • Easier to perform than the BBQ roll as it only requires identifying the side of weaker nystagmus 5

Treatment Efficacy and Considerations

• A single canalith repositioning procedure (CRP) is >10 times more effective than a week of Brandt-Daroff exercises 2, 3
• Success rates for the Epley maneuver reach 93.4% with repeated treatments 6
• Postprocedural restrictions are NOT recommended after CRP for posterior canal BPPV 1, 2
• Patients may experience mild residual symptoms for a few days to weeks after successful treatment 2

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients 2
• Self-administered CRP appears more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 2

Important Clinical Considerations

• Avoid routine use of vestibular suppressant medications (antihistamines, benzodiazepines) for BPPV treatment 1, 2
• If symptoms persist after initial treatment, patients should be reevaluated for:
  • Persistent BPPV that may respond to additional repositioning maneuvers
  • Involvement of other semicircular canals
  • Coexisting vestibular conditions 2
• Repeat CRPs can achieve success rates of 90-98% for persistent BPPV 2
• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment 2

When to Refer

• Patients with severe disabling symptoms, history of falls, or difficulty moving should be referred to a healthcare professional experienced in performing repositioning maneuvers 2
• Surgical canal plugging should be considered only in selected cases of same-canal, same-side intractable severe BPPV 4

The Epley maneuver remains the gold standard treatment for posterior canal BPPV with strong evidence supporting its efficacy, safety, and superiority over medication-based approaches 1, 2, 3, 7.