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

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

The initial treatment for Benign Paroxysmal Positional Vertigo (BPPV) should be a canalith repositioning procedure (CRP), specifically the Epley maneuver for posterior canal BPPV, which has a success rate of approximately 80% with just 1-3 treatments. 1

Diagnosis and Canal Identification

• BPPV is diagnosed through bedside testing, primarily the Dix-Hallpike test for posterior canal BPPV (most common type) and the supine roll test for horizontal canal BPPV 2, 1
• Posterior canal BPPV is diagnosed when vertigo with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 2
• If the Dix-Hallpike test shows horizontal or no nystagmus, the supine roll test should be performed to assess for lateral semicircular canal BPPV 2

First-Line Treatment by Canal Type

Posterior Canal BPPV (80-90% of cases)

• The Epley maneuver (canalith repositioning procedure) is the treatment of choice with strong evidence 1, 3
• The procedure involves 5 specific steps:
  1. Patient seated with head turned 45° toward affected ear
  2. Rapidly moved to supine position with head hanging 20° below horizontal for 20-30 seconds
  3. Head turned 90° to unaffected side for 20 seconds
  4. Head and body turned another 90° (face down position) for 20-30 seconds
  5. Return to sitting position 2, 1
• Success rates for the Epley maneuver reach 90-98% when performed correctly 1, 4
• The Semont maneuver (Liberatory maneuver) is an effective alternative with similar efficacy 1, 5

Horizontal Canal BPPV (10-15% of cases)

• The Barbecue Roll Maneuver (Lempert maneuver) is first-line treatment, involving rolling the patient 360 degrees in sequential steps 1, 5
• The Gufoni maneuver is an easier alternative with comparable efficacy 6, 5
• Treatment success rates range from 86-100% with up to 4 CRP treatments 2

Important Clinical Considerations

• Postprocedural restrictions after CRP are NOT recommended 2, 1
• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 2, 1
• Medications may be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) 1
• Patients should be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms 2

Alternative or Adjunctive Treatments

• Vestibular rehabilitation exercises may be offered as an option, either self-administered or clinician-guided 2, 1
• Self-administered CRP can be taught to motivated patients (64% improvement) and is more effective than self-treatment with Brandt-Daroff exercises (23% improvement) 1, 7
• Observation with follow-up is an acceptable initial management option for some patients 2

Management of Treatment Failures

• If symptoms persist after initial treatment, patients should be reevaluated for:
  • Persistent BPPV that may respond to additional repositioning maneuvers
  • Canal conversion (changing from one type of BPPV to another, occurs in ~6% of cases)
  • Coexisting vestibular conditions
  • Central nervous system disorders 2, 1
• Repeat CRPs can achieve success rates of 90-98% for persistent BPPV 2, 1
• For cases refractory to multiple CRPs, surgical options like canal plugging may be considered, with success rates >96% 2

Risk Factors for Recurrence

• Elderly patients have a significantly higher recurrence rate 4
• History of head trauma or vestibular neuropathy is associated with higher recurrence rates 4
• Patients with secondary BPPV (due to other conditions) may have lower success rates with repositioning maneuvers compared to those with idiopathic BPPV 8

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers 1, 3
• Failing to reassess patients after initial treatment 2
• Missing canal conversions or multiple canal involvement 2, 6
• Not considering underlying vestibular pathology in patients with persistent or recurrent symptoms 2, 9