What are the treatment options for benign positional vertigo (BPV)?

Treatment Options for Benign Positional Vertigo

The primary treatment for benign paroxysmal positional vertigo (BPPV) should be canalith repositioning procedures rather than medications, as these maneuvers directly address the underlying cause and have substantially higher treatment response rates. 1

Diagnosis and Initial Assessment

• BPPV should be diagnosed when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, which is performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down 1
• If the Dix-Hallpike test is negative but BPPV is still suspected, a supine roll test should be performed to assess for lateral semicircular canal BPPV 1
• Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo before initiating treatment 1

First-Line Treatment

• Canalith repositioning procedures (CRP) such as the Epley maneuver should be the first-line treatment for posterior canal BPPV, with treatment response rates of 78.6%-93.3% 1, 2
• Patients should be treated with CRP or referred to a clinician who can perform these maneuvers 1
• Postprocedural postural restrictions after CRP are NOT necessary 1

Medication Recommendations

• Vestibular suppressant medications such as antihistamines (including meclizine) and benzodiazepines are NOT recommended as routine treatment for BPPV 1
• Despite meclizine being FDA-indicated "for the treatment of vertigo associated with diseases affecting the vestibular system" 3, clinical practice guidelines specifically recommend against its routine use for BPPV 1
• Long-term use of vestibular suppressants can interfere with the brain's natural compensation mechanisms for vestibular disorders, potentially prolonging symptoms 4
• Vestibular suppressants increase fall risk, especially in elderly patients 4, 2

Alternative Treatment Options

• Vestibular rehabilitation, either self-administered or with a clinician, may be offered as an option for treatment of BPPV 1, 5
• Observation with follow-up may be offered as initial management for patients with BPPV 1
• In a study comparing betahistine and dimenhydrinate with repositioning maneuvers alone, adding medications showed no superiority over repositioning maneuvers by themselves 6

Follow-Up Care

• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 1
• For patients who fail initial treatment, evaluation for persistent BPPV or underlying peripheral vestibular or CNS disorders should be performed 1
• Keeping a journal of vertigo symptoms can help with accurate diagnosis during follow-up 4

Special Considerations

• Patients should be questioned for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling 1
• Patients should be counseled regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up 1
• For patients who cannot undergo repositioning maneuvers due to physical limitations, vestibular rehabilitation may be considered as an alternative 5

Common Pitfalls to Avoid

• Routine use of vestibular suppressant medications delays recovery and has side effects including drowsiness and cognitive deficits 4, 2
• Unnecessary radiographic imaging and vestibular testing should be avoided unless the diagnosis is uncertain or there are additional symptoms unrelated to BPPV 1
• Continuing vestibular suppressants long-term can delay recovery by interfering with central compensation 4