What is the treatment for Benign Paroxysmal Positional Vertigo (BPPV)?

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

The Epley maneuver (canalith repositioning procedure) is the first-line treatment for posterior canal BPPV, achieving approximately 80% success with just 1-3 treatments, and should be performed immediately upon diagnosis without the use of vestibular suppressant medications. 1

Diagnosis and Canal Identification

Before treatment, you must identify which semicircular canal is affected:

• Posterior canal BPPV (80-90% of cases): Diagnose with the Dix-Hallpike test, which provokes vertigo with torsional, upbeating nystagmus 1
• Horizontal/lateral canal BPPV (10-15% of cases): Diagnose with the supine roll test, which shows either geotropic (toward ground) or apogeotropic (away from ground) nystagmus patterns 1
• Anterior canal BPPV: Rare variant with weaker evidence for treatment approaches 2

Treatment by Canal Type

Posterior Canal BPPV (Most Common)

Primary treatment options (choose based on patient mobility and clinician preference):

• Epley Maneuver (first-line): Patient sits upright with head turned 45° toward affected ear, rapidly lay back to supine head-hanging 20° position for 20-30 seconds, then sequentially turn head and body through specific positions 1. Success rate: 80.5% negative Dix-Hallpike by day 7 1

• Semont Maneuver (alternative): Rapid movement from sitting to side-lying on affected side for 30 seconds, then rapid movement to opposite side-lying position without changing head position relative to shoulder 1. Success rate: 71% at 1 week, 94.2% at 6 months 1

Both maneuvers have comparable efficacy 2, 3, though one study showed the Epley had superior outcomes at 3-month follow-up 1

Horizontal Canal BPPV

Treatment depends on the variant:

• Geotropic variant (most common and responsive):

  • Barbecue Roll Maneuver (Lempert 360° roll): Start supine, roll head/body toward unaffected side, continue rolling until nose-down/prone, complete full 360° rotation. Each position held 15-30 seconds 4, 1. Success rates: 50-100% 4
  • Gufoni Maneuver: Move from sitting to side-lying on unaffected side for 30 seconds, then quickly turn head 45-60° toward ground and hold 1-2 minutes 4, 1. Success rate: 93% 4

• Apogeotropic variant: Modified Gufoni Maneuver—move to side-lying on affected side (opposite of geotropic), then turn head toward ground 1

Treatment Protocol and Frequency

• Perform 1-3 maneuvers during initial visit 1. Clinical practice varies: some perform one cycle, others repeat until symptoms extinguish 5
• If symptoms persist after first maneuver, repeat immediately or at follow-up 5
• Reassess within one month to confirm resolution 5
• For persistent BPPV: Repeat maneuvers achieve cumulative success rates of 90-98% 1, 5

What NOT to Do

Do NOT routinely use vestibular suppressant medications (antihistamines like meclizine, benzodiazepines) as primary treatment for BPPV 1. These medications:

• Have no evidence of effectiveness as definitive treatment 1
• Cause drowsiness, cognitive deficits, and increased fall risk (especially in elderly) 1
• Interfere with central compensation in vestibular conditions 1
• Decrease diagnostic sensitivity during Dix-Hallpike testing 1

Exception: Consider vestibular suppressants only for short-term management of severe nausea/vomiting in severely symptomatic patients 1. Meclizine is FDA-approved for vertigo associated with vestibular system diseases at 25-100 mg daily in divided doses 6, but should not replace repositioning maneuvers.

Do NOT impose postprocedural restrictions after canalith repositioning for posterior canal BPPV 1

Alternative and Adjunctive Treatments

• Brandt-Daroff exercises: Less effective than repositioning maneuvers (24% vs 71-74% success at 1 week) 1. A single Epley treatment is >10 times more effective than a week of Brandt-Daroff exercises 1. Reserve for patients with physical limitations preventing repositioning maneuvers 1

• Self-administered CRP: Can be taught to motivated patients with 64% improvement rate (vs 23% for self-administered Brandt-Daroff) 1

• Vestibular Rehabilitation Therapy: May be offered as adjunct, including habituation and gaze stabilization exercises 1

Treatment Failures and Complications

If symptoms persist after initial treatment, reevaluate for:

• Persistent BPPV requiring additional maneuvers 1, 5
• Canal conversion (6-7% of cases): BPPV changes from one canal to another during treatment, requiring appropriate repositioning for newly affected canal 1, 5
• Multiple canal involvement 5
• Coexisting vestibular conditions 1
• CNS disorders simulating BPPV 1, 5

For refractory cases: Surgical canal plugging may be considered with success rates >96% 5

Special Patient Populations

Patients with physical limitations (cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, spinal issues):

• May not be candidates for repositioning maneuvers 1
• Consider Brandt-Daroff exercises as alternative 1
• May need specialized examination tables or modified approaches 1

Elderly patients: Particularly at risk for falls with BPPV—9% of geriatric clinic patients have undiagnosed BPPV, with three-quarters having fallen within previous 3 months 1. Prioritize treatment to reduce fall risk.

Common Pitfalls to Avoid

• Failing to identify the affected canal and variant before treatment 4
• Not moving patient quickly enough during Semont maneuver, reducing effectiveness 1
• Relying on medications instead of repositioning maneuvers 5
• Failing to reassess after initial treatment 5
• Not recognizing canal conversions during treatment 5
• Performing exercises with insufficient frequency (Brandt-Daroff requires three times daily) 1