What is the recommended treatment for Benign Paroxysmal Positional Vertigo (BPPV) using the Epley maneuver?

The Epley Maneuver for Treatment of Benign Paroxysmal Positional Vertigo

The Epley maneuver (canalith repositioning procedure) is the first-line treatment for posterior canal BPPV with a success rate of approximately 80% after just 1-3 treatments and patients treated with this procedure have 6.5 times greater chance of symptom improvement compared to controls. 1, 2

Diagnosis of BPPV

• BPPV is diagnosed through bedside testing, primarily the Dix-Hallpike test for posterior canal BPPV (85-95% of cases) and the supine roll test for horizontal canal BPPV (5-15% of cases) 1, 2
• The Dix-Hallpike test has a sensitivity of 82% and specificity of 71% for posterior canal BPPV, though a negative test does not necessarily rule out BPPV 1
• Normal medical imaging and laboratory testing cannot confirm BPPV 2

Epley Maneuver Technique for Posterior Canal BPPV

The Epley maneuver involves a specific sequence of head and body positions:

1. Position the patient upright with head turned 45° toward the affected ear (the ear positive on Dix-Hallpike testing) 1
2. Rapidly lay the patient back to the supine head-hanging 20° position and maintain for 20-30 seconds 1
3. Turn the head 90° toward the unaffected side and hold for about 20 seconds 1
4. Turn the head a further 90° (requiring the patient's body to move to lateral decubitus position) so the patient's head is nearly face-down, holding for 20-30 seconds 1
5. Bring the patient to the upright sitting position, completing the maneuver 1

Efficacy of Treatment

• Success rates for the Epley maneuver for posterior canal BPPV include 80.5% negative Dix-Hallpike by day 7 2
• Meta-analysis shows patients treated with the Epley maneuver have 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20) 1, 2
• A single Epley maneuver is >10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 2
• Recent research shows the number-needed-to-treat is 3 patients to achieve one complete resolution of vertigo at 1 week 3

Alternative Treatments

• The Liberatory Maneuver (Semont maneuver) is an alternative treatment for posterior canal BPPV with good evidence 2
• For horizontal canal BPPV, the Barbecue Roll Maneuver (Lempert maneuver) is the first-line treatment 2
• Self-administered Epley maneuver can be taught to motivated patients and appears more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 2

Post-Treatment Considerations

• Postprocedural restrictions are NOT recommended after the Epley maneuver for posterior canal BPPV 2
• Patients may experience mild residual symptoms for a few days to weeks after successful treatment 2
• After a successful treatment, approximately 14.66% of patients may have recurrent attacks of BPPV during the first year 4

Special Considerations and Pitfalls

• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment 2
• Patients with physical limitations may need specialized examination tables or modified approaches 2
• The etiology of BPPV can affect treatment success rates - idiopathic BPPV shows higher success rates with the Epley maneuver than secondary BPPV 4
• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV as they can cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk, and interference with central compensation 2

When to Consider Additional Treatment

• If symptoms persist after initial treatment, patients should be reevaluated for persistent BPPV, involvement of other semicircular canals, coexisting vestibular conditions, or possible CNS disorders 2
• Repeat Epley maneuvers can achieve success rates of 90-98% for persistent BPPV 2, 4
• Patients with severe disabling symptoms, history of falls, or difficulty moving should be referred to a healthcare professional experienced in performing repositioning maneuvers 2