What is the recommended 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 specific maneuver determined by the affected canal. 1

Diagnosis and Canal Identification

• BPPV diagnosis is made 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 diagnosed when the Dix-Hallpike maneuver provokes vertigo with torsional, upbeating nystagmus 2
• Lateral canal BPPV is diagnosed when the supine roll test exhibits horizontal nystagmus 2
• Radiographic imaging and vestibular testing should NOT be ordered in 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)

• The Epley maneuver is the first-line treatment with strong evidence (80% success rate with 1-3 treatments) 1
  • Patient sits upright with head turned 45° toward affected ear
  • Rapidly lay back to supine head-hanging 20° position for 20-30 seconds
  • Follow with series of head and body turns 1
• The Semont (Liberatory) maneuver is an effective alternative with 71% symptom resolution at 1 week 1, 3

Horizontal Canal BPPV

• The Barbecue Roll Maneuver (Lempert maneuver) is first-line treatment, involving rolling the patient 360 degrees in sequential steps 1, 4
• The Gufoni maneuver is an easier alternative that only requires identifying the side of weaker nystagmus 4

Treatment Efficacy and Follow-up

• Success rates for CRP (Epley) for posterior canal BPPV are 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
• Clinicians should NOT recommend postprocedural postural restrictions after CRP for posterior canal BPPV 2
• Patients should be reassessed within 1 month after treatment to document resolution or persistence of symptoms 2, 5

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

Medication Use in BPPV

• Clinicians should NOT routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines 2, 1
• Vestibular suppressants can cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interference with central compensation 1
• These medications may be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 1

Treatment Failures and Persistent Symptoms

• 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
  • Possible CNS disorders 1, 5
• Repeat CRPs can achieve success rates of 90-98% for persistent BPPV 1

Special Considerations and Safety

• Assess patients for modifying factors including impaired mobility/balance, CNS disorders, lack of home support, and increased fall risk 5
• Elderly patients are particularly vulnerable, with studies showing 9% of patients referred to geriatric clinics having undiagnosed BPPV, and three-quarters of those having fallen within the previous 3 months 1
• 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 may need specialized examination tables or modified approaches 1
• Inform patients about recurrence rates: approximately 5-13.5% at 6 months, 10-18% at 1 year, and up to 36% over time 5

Patient Education

• Educate patients regarding the impact of BPPV on their safety, potential for recurrence, and importance of follow-up 2
• Explain that residual symptoms may persist for a few days to weeks after successful treatment 5
• Instruct patients to return sooner if symptoms persist or worsen 5

By following this evidence-based approach to BPPV treatment, clinicians can effectively manage this common condition while minimizing unnecessary testing, medications, and specialist referrals 6.