What is the treatment for 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 being the most effective treatment for posterior canal BPPV, achieving success rates of approximately 80% with just 1-3 treatments. 1

Diagnosis

• BPPV is diagnosed through specific bedside tests: 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
• Diagnosis is confirmed when vertigo with characteristic nystagmus is provoked during these positioning tests 2
• Radiographic imaging and vestibular testing should NOT be ordered for patients who meet diagnostic criteria for BPPV unless additional signs/symptoms inconsistent with BPPV are present 2

Treatment Based on Canal Involvement

Posterior Canal BPPV (Most Common)

• Epley maneuver (first-line treatment):
  • Patient sits upright with head turned 45° toward affected ear
  • Rapidly lay back to supine head-hanging position for 20-30 seconds
  • Turn head 90° to opposite side and hold for 20-30 seconds
  • Roll body and head another 90° in same direction and hold for 20-30 seconds
  • Return to sitting position 1, 3
• Semont maneuver (alternative):
  • Patient sits upright, head turned 45° away from affected ear
  • Quickly moved to side-lying position on affected side for 30 seconds
  • Rapidly moved to opposite side-lying position without changing head position relative to shoulder
  • Return to upright position 1

Horizontal Canal BPPV

• Barbecue Roll Maneuver (Lempert maneuver):
  • Involves rolling the patient 360 degrees in sequential steps 1
• Gufoni Maneuver for geotropic variant:
  • Patient moves from sitting to side-lying position on unaffected side for 30 seconds
  • Quickly turns head 45°-60° toward the ground and holds for 1-2 minutes 1

Treatment Efficacy

• Success rates for Epley maneuver for posterior canal BPPV: 80.5% negative Dix-Hallpike by day 7 1
• Patients treated with CRP 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 1, 3
• The Epley and Semont maneuvers have comparable efficacy 3, 4

Important Clinical Considerations

• Postprocedural restrictions after CRP are NOT recommended 2, 1
• Patients may experience mild residual symptoms for a few days to weeks after successful treatment 2, 1
• Reassess patients within 1 month after treatment to document resolution or persistence of symptoms 2
• If symptoms persist, evaluate for:
  • Unresolved BPPV (may need additional repositioning maneuvers)
  • Canal conversion (occurs in 6-7% of cases)
  • Involvement of multiple canals
  • Other vestibular or central nervous system disorders 1

Medication Use

• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 2, 1, 5
• These medications:
  • Show no evidence of effectiveness as definitive treatment
  • Can cause significant adverse effects (drowsiness, cognitive deficits)
  • Increase risk of falls, especially in elderly patients
  • May interfere with central compensation 1, 5
• Limited role: May be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 1, 5

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients (64% improvement)
• More effective than self-treatment with Brandt-Daroff exercises (23% improvement) 1
• Telehealth consultations can be effective for guiding patients through repositioning maneuvers 6

Special Considerations

• Elderly patients are at particular risk for falls with BPPV 1
• Patients with physical limitations may need specialized examination tables or modified approaches 1
• Nausea and vomiting occur in approximately 12% of patients undergoing the Epley maneuver 5
• Canal conversion can occur in about 6-7% of cases during treatment 1

Common Pitfalls to Avoid

• Failing to diagnose BPPV due to unfamiliarity with diagnostic maneuvers 2
• Using medications as primary treatment instead of repositioning maneuvers 2, 1
• Not reassessing patients after initial treatment 2
• Performing repositioning maneuvers incorrectly (not moving quickly enough during the Semont maneuver can reduce effectiveness) 1
• Not recognizing that multiple treatment sessions may be needed (61.52% of cases require repeated sessions) 7