What is the initial treatment for benign positional vertigo?

Initial Treatment for Benign Paroxysmal Positional Vertigo

Clinicians should treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure (CRP) as the initial treatment. 1

Diagnosis and Classification

• BPPV is diagnosed when vertigo with characteristic nystagmus is provoked by the Dix-Hallpike maneuver (for posterior canal BPPV) or the supine roll test (for lateral canal BPPV) 1, 2
• Posterior canal BPPV is the most common form (80-90% of cases), followed by lateral (horizontal) canal BPPV (10-15% of cases) 2, 3

First-Line Treatment Options

For Posterior Canal BPPV:

• Canalith Repositioning Procedure (Epley maneuver) - Strong recommendation with success rates of 80-98% with just 1-3 treatments 1, 2

  • Involves a specific sequence of head positions:
    1. Patient seated upright with head turned 45° toward affected ear
    2. Rapidly moved to supine position with head hanging 20° below horizontal
    3. Head turned 90° to unaffected side
    4. Head and body turned another 90° (face down position)
    5. Return to sitting position 2, 3

• Liberatory Maneuver (Semont maneuver) - Alternative treatment with comparable efficacy 1, 2

  • Steps include:
    1. Start with patient sitting with head turned away from affected side
    2. Quickly move patient to side-lying position toward affected side with head turned up
    3. After nystagmus ceases (20+ seconds), quickly move patient through sitting position to opposite side-lying position with head facing down
    4. Return patient to sitting position 1

For Lateral (Horizontal) Canal BPPV:

• Barbecue Roll Maneuver (Lempert maneuver) - First-line treatment involving rolling the patient 360 degrees in sequential steps 2, 4
• Gufoni Maneuver - Alternative treatment with success rates of 86-100% 3, 4

Treatment Efficacy

• Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20) 2, 5
• A single CRP is >10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 2, 5
• Success rates for CRP (Epley) for posterior canal BPPV are 80.5% negative Dix-Hallpike by day 7 2

Important Clinical Considerations

• Do NOT routinely prescribe vestibular suppressant medications (antihistamines, benzodiazepines) for BPPV treatment 1, 3
• No postprocedural restrictions are needed after canalith repositioning procedures 1
• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 1, 3
• Multiple CRP treatments may be necessary, with increasing success rates after each session (32-90% after first treatment, up to 100% after five sessions) 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, 2

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers 1, 3
• Failing to reassess patients after initial treatment 1
• Missing canal conversions (changing from one type of BPPV to another), which occurs in about 6-7% of cases during treatment 1, 2
• Not recognizing that patients with physical limitations may need specialized examination tables or modified approaches 2

When to Consider Referral

• Patients with severe disabling symptoms, history of falls, or difficulty moving should be referred to a healthcare professional experienced in performing repositioning maneuvers 2
• Patients with persistent symptoms after multiple repositioning attempts should be evaluated for unresolved BPPV or underlying peripheral vestibular or central nervous system disorders 1