What is the management of Benign Paroxysmal Positional Vertigo (BPPV)?

Management of Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) should be the first-line treatment for BPPV, with the Epley maneuver being the most effective treatment for posterior canal BPPV, achieving success rates of approximately 80% with just 1-3 treatments. 1, 2

Diagnosis and Canal Identification

• Diagnose posterior canal BPPV (80-90% of cases) using the Dix-Hallpike test, which provokes vertigo with torsional, upbeating nystagmus 3, 1
• If the Dix-Hallpike test is negative but BPPV is still suspected, perform a supine roll test to assess for horizontal canal BPPV (10-15% of cases) 3, 1
• Differentiate BPPV from other causes of imbalance, dizziness, and vertigo before initiating treatment 1

First-Line Treatment Based on Canal Involvement

Posterior Canal BPPV (Most Common)

• Epley maneuver (CRP) - performed in the following sequence: 3, 2

  1. Patient sits upright with head turned 45° toward the affected ear
  2. Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
  3. Turn head 90° toward the unaffected side and hold for 20 seconds
  4. Turn head and body another 90° (facing down) and hold for 20-30 seconds
  5. Return patient to upright sitting position

• Semont maneuver (Liberatory maneuver) - an effective alternative with 71-94% success rates: 3, 2

  1. Patient sits upright with head turned 45° away from affected ear
  2. Quickly move to side-lying position on the affected side for 30 seconds
  3. Rapidly move to opposite side-lying position without changing head position relative to shoulder
  4. Return to upright position

Horizontal Canal BPPV

• Barbecue Roll Maneuver (Lempert maneuver) - involves rolling the patient 360 degrees in sequential steps 2
• Gufoni Maneuver - for geotropic variant 2
• Modified Gufoni Maneuver - for apogeotropic variant 2

Treatment Efficacy and Follow-Up

• Success rates for CRP (Epley) for posterior canal BPPV are 80.5% negative Dix-Hallpike by day 7 2
• Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls 2
• Reassess patients within 1 month after initial treatment to confirm symptom resolution 3, 1
• For patients who fail initial treatment, evaluate for persistent BPPV or underlying peripheral vestibular or CNS disorders 3, 1

Important Clinical Considerations

• Do NOT recommend postprocedural restrictions after CRP for posterior canal BPPV - evidence shows they provide minimal additional benefit 3, 1

• Do NOT routinely use vestibular suppressant medications (antihistamines, benzodiazepines) for BPPV treatment 3, 1

  • These medications can cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk (especially in elderly patients), and interference with central compensation 1, 2
  • They may be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 2

• Self-administered CRP can be taught to motivated patients and appears more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 3, 2

Alternative Management Options

• Observation with follow-up may be offered as initial management, with spontaneous resolution occurring in 15-85% of patients at 1 month without intervention 3
• Brandt-Daroff exercises can be implemented, though they are less effective than repositioning maneuvers (24% vs 71-74% success rate at 1 week) 2

Special Considerations and Risk Assessment

• Assess patients for modifying factors including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling 3, 1
• Elderly patients are particularly at risk for falls with BPPV 2
• Patients with physical limitations may need specialized examination tables or modified approaches 2

Common Pitfalls to Avoid

• Routine use of vestibular suppressant medications delays recovery and has side effects 1
• Unnecessary radiographic imaging and vestibular testing should be avoided unless the diagnosis is uncertain or there are additional symptoms unrelated to BPPV 3, 1
• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment 2
• Failing to reassess patients after the initial treatment period can lead to persistent symptoms 2
• Not performing Brandt-Daroff exercises with sufficient frequency (three times daily) can reduce their effectiveness 2