What is the first line of treatment for a patient with Benign Paroxysmal Positional Vertigo (BPPV)?

First-Line Treatment for Benign Paroxysmal Positional Vertigo (BPPV)

Clinicians should treat patients with posterior canal BPPV with a canalith repositioning procedure (CRP), specifically the Epley maneuver, as the first-line treatment. 1, 2

Diagnosis Before Treatment

• BPPV is diagnosed through bedside testing, primarily the Dix-Hallpike test for posterior canal BPPV (most common, 80-90% of cases) and the supine roll test for horizontal canal BPPV (10-15% of cases) 2, 1
• Posterior canal BPPV is confirmed when the Dix-Hallpike maneuver provokes vertigo with characteristic torsional, upbeating nystagmus 1
• Lateral (horizontal) canal BPPV should be assessed using the supine roll test if the Dix-Hallpike test shows horizontal or no nystagmus 1

Treatment Based on Canal Involvement

Posterior Canal BPPV (Most Common)

• The Epley maneuver (canalith repositioning procedure) is the first-line treatment with a success rate of approximately 80% with just 1-3 treatments 2, 3
• The Epley maneuver involves a series of specific head and body positions to move displaced otoconia from the semicircular canal back to the vestibule 2
• The Semont maneuver (Liberatory maneuver) is an effective alternative with comparable outcomes 2, 4
• A single CRP is more than 10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 2, 4

Horizontal Canal BPPV

• The Barbecue Roll Maneuver (Lempert maneuver) is the first-line treatment, involving rolling the patient 360 degrees in sequential steps 2, 5
• The Gufoni Maneuver is an alternative that may be easier to perform as it only requires identifying the side of weaker nystagmus 2, 5

Important Clinical Considerations

• Postprocedural postural restrictions are NOT recommended after CRP for posterior canal BPPV 1, 2, 6
• Clinicians should NOT routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines 2, 6
• Vestibular medications can cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk (especially in elderly patients), and interference with central compensation 2
• Reassess patients within 1 month after treatment to document resolution or persistence of symptoms 1, 6

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients and appears more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 2
• Patients with physical limitations may need specialized examination tables or modified approaches 2

Common Pitfalls and Caveats

• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment 2, 7
• Repeated testing and treatment of BPPV within the same session is safe and effective with low risk of canal conversion 7
• Approximately 25-50% of patients with recurrent BPPV may have associated vestibular pathology that requires additional evaluation 6
• Patients with persistent symptoms after initial treatment should be reevaluated for persistent BPPV, involvement of other semicircular canals, coexisting vestibular conditions, or possible CNS disorders 2
• Repeat CRPs can achieve success rates of 90-98% for persistent BPPV 2

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
• Patients with physical limitations, including cervical stenosis, severe rheumatoid arthritis, or spinal issues, may require specialized approaches 2