Treatment for Benign Paroxysmal Positional Vertigo (BPPV)
The first-line treatment for BPPV is the canalith repositioning procedure (CRP), specifically the Epley maneuver for posterior canal BPPV, which achieves an 80% success rate with just 1-3 treatments and should NOT be followed by postprocedural restrictions or vestibular suppressant medications. 1, 2
Initial Treatment Approach by Canal Type
Posterior Canal BPPV (80-90% of cases)
Perform the Epley maneuver immediately upon diagnosis 1, 2:
- Patient sits upright with head turned 45° toward the affected ear
- Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
- Turn head 90° to opposite side, hold 20-30 seconds
- Roll patient onto side with nose pointing down, hold 20-30 seconds
- Return patient to upright sitting position 2, 3
Alternative: Semont (Liberatory) maneuver 2, 4:
- Rapid side-to-side body movements with head turned 45° away from affected ear
- Success rate of 94.2% at 6 months, though Epley shows superior outcomes at 3 months 2
Horizontal Canal BPPV (10-15% of cases)
- Barbecue Roll (Lempert) maneuver: Roll patient 360° in sequential 90° steps, success rate 50-100% 2
- Gufoni maneuver: Side-lying on unaffected side for 30 seconds, then turn head 45-60° toward ground for 1-2 minutes, success rate 93% 2
For apogeotropic variant 2:
- Modified Gufoni maneuver: Side-lying on affected side (opposite of geotropic variant) 2
Critical Post-Treatment Instructions
Do NOT recommend postprocedural restrictions 1, 2:
- Strong evidence shows restrictions provide no benefit and may cause complications 2
- Patients can resume normal activities immediately 3
Medication Management
Do NOT routinely prescribe vestibular suppressant medications (antihistamines, benzodiazepines, meclizine) 1, 2:
- No evidence of effectiveness as primary treatment 2
- Causes drowsiness, cognitive deficits, increased fall risk in elderly 2
- Interferes with central compensation mechanisms 2
- Exception: May consider short-term use ONLY for severe nausea/vomiting in severely symptomatic patients 2
Treatment Efficacy Data
- 80.5% negative Dix-Hallpike by day 7 2
- Patients have 6.5 times greater chance of symptom improvement vs controls (OR 6.52; 95% CI 4.17-10.20) 2
- Single CRP is >10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 2, 6
Self-Treatment Options
Self-administered CRP can be taught to motivated patients 2, 3:
- 64% improvement rate vs 23% with Brandt-Daroff exercises 2, 3
- Patient should first receive at least one properly performed Epley maneuver from trained clinician before attempting home treatment 3
- Each cycle involves 5 sequential steps, holding each position 20-30 seconds 3
Follow-Up and Treatment Failures
Reassess within 1 month if symptoms persist 1:
- Repeat CRPs achieve 90-98% success for persistent BPPV 2
- Evaluate for canal conversion (occurs in 6-7% of cases) 2, 3
- Consider involvement of other semicircular canals 2
- Rule out coexisting vestibular conditions or CNS disorders 1, 2
Special Populations and Risk Factors
Assess for modifying factors before treatment 1, 2:
- Impaired mobility or balance
- CNS disorders
- Lack of home support
- Increased fall risk (especially elderly—9% of geriatric clinic patients have undiagnosed BPPV, three-quarters had fallen within 3 months) 2
- Cervical spine pathology (may need modified approaches or Brandt-Daroff exercises instead) 2, 7
Common Pitfalls to Avoid
- Ordering unnecessary imaging or vestibular testing when diagnostic criteria are met 1
- Prescribing vestibular suppressants as primary treatment 1, 2, 5
- Recommending postprocedural restrictions 1, 3
- Failing to identify the affected canal and variant before treatment 2
- Not moving patient quickly enough during maneuvers reduces effectiveness 2
- Not reassessing treatment failures for persistent BPPV or alternative diagnoses 1, 2