How to treat Benign Paroxysmal Positional Vertigo (BPPV)?

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) are the first-line treatment for BPPV, with the Epley maneuver showing approximately 80% success rate with just 1-3 treatments for posterior canal BPPV. 1

Diagnosis

• BPPV is diagnosed through bedside testing, primarily the Dix-Hallpike test for posterior canal BPPV and the supine roll test for horizontal canal BPPV 1
• Normal medical imaging and laboratory testing cannot confirm BPPV 2
• The examiner will observe for characteristic nystagmus patterns that confirm the diagnosis and identify the affected canal 2

Treatment Based on Canal Involvement

Posterior Canal BPPV (80-90% of cases)

• Epley Maneuver (first-line treatment):

  • Step 1: Patient sits upright with head turned 45° toward affected ear
  • Step 2: Patient rapidly lies back to supine head-hanging position for 20-30 seconds
  • Step 3: Head turned 90° toward unaffected side, held for 20 seconds
  • Step 4: Head and body turned another 90° (face down position), held for 20-30 seconds
  • Step 5: Patient returns to sitting position 2, 1

• Semont Maneuver (alternative treatment):

  • Involves rapid movement from sitting to side-lying position on affected side, then quickly to opposite side-lying position 1
  • Shows 71% symptom resolution at 1 week, though slightly less effective than Epley 1

Horizontal Canal BPPV (10-15% of cases)

• Barbecue Roll Maneuver (Lempert maneuver):

  • Involves rolling the patient 360° in sequential steps
  • Each position held for 15-30 seconds or until nystagmus stops 2

• Gufoni Maneuver for geotropic variant:

  • Patient moves from sitting to side-lying position on unaffected side
  • Head quickly turned 45°-60° toward the ground 1

Treatment Efficacy

• Patients treated with CRP (Epley) have 6.5 times greater chance of symptom improvement compared to controls 1
• A single CRP is >10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 1, 3
• Success rates for posterior canal BPPV with Epley maneuver range from 50-95% after a single treatment 2
• Multiple studies show odds ratios for symptom resolution ranging from 4.2 to 107.7 compared to controls 2

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients with 64% improvement rate 1
• Self-administered CRP is more effective than self-treatment with Brandt-Daroff exercises (64% vs 23% improvement) 1
• Patients can be taught these maneuvers by healthcare providers with proper supervision 2

Medication Use

• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 1
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases but is not recommended as primary treatment for BPPV 4
• Medications may be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) 1
• Vestibular suppressants can cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 1, 4

Post-Treatment Considerations

• Postprocedural restrictions are NOT recommended after CRP for posterior canal BPPV 1
• Patients may experience mild residual symptoms for a few days to weeks after successful treatment 2
• If symptoms persist after initial treatment, patients should be reevaluated for:
  • Persistent BPPV that may respond to additional repositioning maneuvers
  • Involvement of other semicircular canals
  • Coexisting vestibular conditions 1

Common Pitfalls and Caveats

• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment 1
• Patients with physical limitations including cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, or spinal issues may not be candidates for standard maneuvers 2
• BPPV has a high recurrence rate of approximately 36% after treatment 3
• Failure to correctly identify the affected canal will result in using the wrong repositioning maneuver 1
• Elderly patients are particularly at risk for falls with BPPV and should be prioritized for prompt treatment 1

When to Refer

• Patients with severe disabling symptoms, history of falls, or difficulty moving should be referred to a healthcare professional experienced in performing repositioning maneuvers 2
• Persistent symptoms despite appropriate treatment may indicate need for specialist evaluation 1