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 and Canal Identification

• BPPV is diagnosed through bedside testing, primarily the Dix-Hallpike test for posterior canal BPPV (which accounts for 80-90% of cases) and the supine roll test for horizontal canal BPPV (10-15% of cases) 1, 2
• The Dix-Hallpike test is performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down 1
• Normal medical imaging and laboratory testing cannot confirm BPPV and should not be routinely ordered in patients who meet diagnostic criteria for BPPV 1, 2

Treatment Based on Canal Involvement

Posterior Canal BPPV (Most Common)

• The Epley maneuver (CRP) is the first-line treatment with success rates of approximately 80% with just 1-3 treatments 1, 2, 3
• The Epley maneuver involves a stepwise sequence:
  1. Patient seated upright with head turned 45° toward affected ear
  2. Rapidly laid back to supine head-hanging 20° position for 20-30 seconds
  3. Head turned 90° toward unaffected side for 20 seconds
  4. Head turned another 90° (with body turning to lateral position) for 20-30 seconds
  5. Return to upright sitting position 1, 2
• The Semont maneuver (Liberatory maneuver) is an effective alternative for posterior canal BPPV with comparable efficacy 2, 4

Horizontal Canal BPPV

• The Barbecue Roll Maneuver (Lempert maneuver) is the first-line treatment for horizontal canal BPPV 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

Treatment Protocol and Follow-up

• If symptoms persist after the first maneuver, the procedure should be repeated during the same visit or at follow-up appointments 3, 6
• Success rates increase with repeated applications of the Epley maneuver, reaching 90-98% when additional repositioning maneuvers are performed for persistent BPPV 2, 3, 6
• Patients should be reassessed within one month after initial treatment to confirm symptom resolution 1, 3
• Postprocedural postural restrictions after CRP for posterior canal BPPV are NOT recommended 1, 2

What NOT to Do

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

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, 7
• A single CRP is more than 10 times more effective than a week of Brandt-Daroff exercises 2

Special Considerations and Pitfalls

• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment and requires appropriate repositioning for the newly affected canal 2, 3, 7
• Patients with physical limitations, including cervical stenosis, severe rheumatoid arthritis, or spinal issues, may need modified approaches 2, 5
• Treatment failures require reevaluation for: persistent BPPV, coexisting vestibular conditions, or serious CNS disorders that may simulate BPPV 2, 3
• Elderly patients are particularly at risk for falls with BPPV and may have higher recurrence rates requiring additional education to minimize fall risk 2, 6