What is the recommended approach for outpatient management of peripheral vertigo?

Outpatient Management of Peripheral Vertigo

The first-line treatment for peripheral vertigo, particularly benign paroxysmal positional vertigo (BPPV), is canalith repositioning procedures (CRPs) with success rates of 80-90% after 1-3 treatments. 1

Diagnosis and Assessment

• BPPV is diagnosed through bedside testing, primarily the Dix-Hallpike test for posterior canal BPPV (most common, 80-90% of cases) and the supine roll test for horizontal canal BPPV (10-15% of cases) 1
• Assess patients for modifying factors including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling 2
• Elderly patients are particularly at risk for falls with BPPV, with studies showing 9% of patients referred to geriatric clinics having undiagnosed BPPV, and three-quarters of those having fallen within the previous 3 months 2

Treatment Based on Canal Type

Posterior Canal BPPV (Most Common)

• The Epley maneuver is the first-line treatment with strong evidence, involving a series of head and body position changes to reposition canaliths 3, 1
• The Semont maneuver (Liberatory Maneuver) is an effective alternative treatment with good evidence 1
• Success rates for CRP (Epley) are approximately 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

Horizontal Canal BPPV

• The Barbecue Roll Maneuver (Lempert maneuver) is the first-line treatment, involving rolling the patient 360 degrees in sequential steps 2, 1
• The Gufoni Maneuver is recommended for geotropic variant of horizontal canal BPPV 1
• The Modified Gufoni Maneuver is recommended for apogeotropic variant 1

Vestibular Rehabilitation Therapy (VRT)

• VRT may be offered as initial therapy or as an adjunct to repositioning maneuvers 2
• VRT includes habituation exercises, adaptation exercises for gaze stabilization, and compensation for vestibular deficits 2
• Cawthorne-Cooksey exercises consist of eye, head, and body movements in increasing difficulty to provoke vestibular symptoms 3
• For BPPV specifically, Brandt-Daroff exercises can be implemented, though they are less effective than repositioning maneuvers (24% vs 71-74% success rate at 1 week) 2, 3
• Home-based therapy appears equally effective as clinician-supervised therapy, though initial instruction is important 3

Medication Management

• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 1, 4
• Meclizine is indicated for vertigo associated with diseases affecting the vestibular system 5, but is not recommended as primary treatment for BPPV as it may mask symptoms without addressing the underlying cause 4
• Vestibular suppressants can cause significant adverse effects, including drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interference with central compensation 1, 4
• Medications may be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 1

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) 1
• No postprocedural restrictions are recommended after CRP for posterior canal BPPV 1

Follow-Up and Treatment Failures

• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 3
• For persistent symptoms, reevaluation should include examination for:
  • Persistent BPPV that may respond to additional repositioning maneuvers 1
  • Involvement of other semicircular canals 3
  • Coexisting vestibular conditions 1
  • Possible CNS disorders 1
• Canal conversion (changing from one type of BPPV to another) occurs in approximately 6-7% of cases during treatment 1

Special Considerations

• Patients with physical limitations including cervical stenosis, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, morbid obesity, ankylosing spondylitis, low back dysfunction, retinal detachment, and spinal cord injuries may need specialized examination tables or modified approaches 2, 1
• Vestibular rehabilitation may be particularly beneficial for elderly patients, potentially decreasing recurrence rates of symptoms 3