What is the recommended management for benign paroxysmal positional vertigo (BPPV)?

Management of Benign Paroxysmal Positional Vertigo (BPPV)

Diagnosis

The Dix-Hallpike maneuver is the definitive diagnostic test for posterior canal BPPV, which accounts for 80-90% of cases. 1 The test is positive when it provokes vertigo with characteristic torsional, upbeating nystagmus. 2, 1

Diagnostic Algorithm:

• Perform the Dix-Hallpike test first by bringing the patient from upright to supine position with head turned 45° to one side and neck extended 20° with the affected ear down 1
• If Dix-Hallpike is negative but BPPV is still suspected, perform the supine roll test to assess for lateral (horizontal) semicircular canal BPPV, which accounts for 10-15% of cases 2, 3
• Do NOT order imaging or vestibular testing unless the diagnosis is uncertain or there are additional symptoms unrelated to BPPV 2, 1

First-Line Treatment

Perform the Epley maneuver (canalith repositioning procedure) immediately for posterior canal BPPV—this is the treatment of choice with success rates of 90-98%. 3, 4 A single treatment achieves 80.5% resolution by day 7, and patients have 6.5 times greater chance of symptom improvement compared to controls. 4

Epley Maneuver Technique:

1. Patient seated upright with head turned 45° toward affected ear 3
2. Rapidly move to supine position with head hanging 20° below horizontal for 20-30 seconds 3, 4
3. Turn head 90° to unaffected side and hold 3
4. Turn head and body another 90° (face down position) and hold 3
5. Return to sitting position 3

Treatment for Lateral Canal BPPV:

• For geotropic variant: Use the Gufoni maneuver (93% success rate) or barbecue roll maneuver (75-90% effectiveness) 2, 4
• For apogeotropic variant: Use the modified Gufoni maneuver (patient lies on affected side) 2, 4

Critical Post-Treatment Instructions

Do NOT recommend postprocedural restrictions after canalith repositioning procedures. 2, 1 There is strong evidence against restrictions such as head elevation during sleep or avoiding certain head movements—these restrictions provide no benefit and may cause complications like neck stiffness. 2

Medication Management

Do NOT prescribe vestibular suppressant medications (antihistamines, benzodiazepines, meclizine) for BPPV treatment. 2, 1, 3 These medications:

• Have no evidence of effectiveness as primary treatment for BPPV 4
• Interfere with the brain's natural compensation mechanisms and prolong symptoms 1
• Increase fall risk, especially in elderly patients 1
• Cause drowsiness and cognitive deficits 4

The only acceptable use of vestibular suppressants is short-term management of severe nausea or vomiting in severely symptomatic patients. 3, 4

Follow-Up and Treatment Failures

Reassess all patients within 1 month after initial treatment to confirm symptom resolution. 1, 3

If Symptoms Persist:

• Repeat the repositioning maneuver—repeat CRPs achieve 90-98% success rates for persistent BPPV 4
• Evaluate for canal conversion (occurs in 6-7% of cases during treatment) 3, 4
• Consider involvement of other semicircular canals 4
• Rule out coexisting vestibular conditions or CNS disorders 3, 4

Alternative Treatment Options

Self-administered CRP can be taught to motivated patients and is significantly more effective (64% improvement) than Brandt-Daroff exercises (23% improvement). 2, 1, 4

Brandt-Daroff exercises are substantially inferior to CRP—a single CRP is more than 10 times more effective than a week of Brandt-Daroff exercises (OR 12.38). 4, 5 These exercises should only be considered for patients with physical limitations preventing repositioning maneuvers. 4

Special Populations and Risk Factors

Assess all patients for modifying factors before treatment: 2, 1

• Impaired mobility or balance 2
• CNS disorders 2
• Lack of home support 2
• Increased fall risk (particularly important in elderly—9% of geriatric clinic patients have undiagnosed BPPV, with three-quarters having fallen in the previous 3 months) 4
• Cervical spine problems, severe rheumatoid arthritis, or cervical radiculopathies that may prevent proper maneuver execution 4

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers is the most common error in BPPV management 3, 6
• Ordering unnecessary brain imaging—current ED practices often include CT/MRI, which are not indicated for straightforward BPPV 6
• Failing to move the patient quickly enough during maneuvers reduces effectiveness 4
• Missing canal conversions or multiple canal involvement leads to apparent treatment failure 3
• Not reassessing patients after initial treatment allows persistent symptoms to go unaddressed 3