What are the treatment maneuvers for benign positional vertigo?

Treatment Maneuvers for Benign Paroxysmal Positional Vertigo

The Epley maneuver is the first-line treatment for posterior canal BPPV (85-95% of cases), achieving approximately 80% success with just 1-3 treatments, and should be performed instead of prescribing medications. 1

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

Primary Treatment: Epley Maneuver 2, 1

The technique involves:

• Patient sits upright with head turned 45° toward the affected ear 1
• Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds 1
• Turn head 90° to opposite side, hold 20-30 seconds 1
• Roll patient onto side with nose pointing downward, hold 20-30 seconds 1
• Return patient to upright sitting position 1

Success rates: 80.5% negative Dix-Hallpike by day 7, with 90-98% success after repeat maneuvers if needed 1

Alternative: Semont (Liberatory) Maneuver 1

This involves rapid lateral movements:

• Patient seated, head turned 45° away from affected ear 1
• Quickly move to side-lying on affected side for 30 seconds 1
• Rapidly swing to opposite side-lying position without changing head-to-shoulder relationship 1
• Return to upright 1

Success rate: 94.2% at 6-month follow-up, though the Epley showed superior outcomes at 3 months 1

Horizontal (Lateral) Canal BPPV (5-15% of cases)

For Geotropic Variant:

Primary: Barbecue Roll (Lempert) Maneuver 1

• Roll patient 360° in sequential 90° steps 1
• Hold each position for 30 seconds 1
• Success rate: 50-100% 1

Alternative: Gufoni Maneuver 1

• Move from sitting to side-lying on unaffected side for 30 seconds 1
• Quickly turn head 45-60° toward ground, hold 1-2 minutes 1
• Success rate: 93% 1

For Apogeotropic Variant:

Modified Gufoni Maneuver 1

• Move from sitting to side-lying on affected side (opposite of geotropic variant) 1
• Turn head 45-60° toward ground, hold 1-2 minutes 1

Critical Post-Treatment Instructions

Do NOT impose postprocedural restrictions - patients can resume normal activities immediately, as restrictions provide no benefit and may cause complications 1, 3

Patients may experience mild residual symptoms for days to weeks after successful treatment 1

When Treatment Fails

If symptoms persist after initial maneuver, reassess for: 1

• Persistent BPPV requiring repeat maneuvers (90-98% success with additional treatments) 1
• Canal conversion (occurs in 6-7% of cases) 1
• Multiple canal involvement or bilateral BPPV 1
• Coexisting vestibular pathology 1
• Central causes if atypical features present 1

Medication Management: What NOT to Do

Do NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV 1, 3

The evidence is clear:

• No evidence these medications are effective as definitive treatment 1
• Canalith repositioning achieves 78.6-93.3% improvement versus only 30.8% with medication alone 3
• Significant adverse effects include drowsiness, cognitive deficits, and increased fall risk (especially in elderly) 1, 3
• Medications interfere with central compensation mechanisms 1

Limited exception: Short-term use only for severe nausea/vomiting during the maneuver itself 1, 3

Self-Treatment Options

Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment 1, 4

Effectiveness comparison: 1, 4

• Self-Epley: 64% improvement 1
• Brandt-Daroff exercises: 23% improvement 1
• A single Epley is >10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 1, 5

Common Pitfalls to Avoid

• Prescribing meclizine instead of performing maneuvers - this addresses neither the cause nor provides effective symptom relief 1, 3
• Imposing sleep restrictions or cervical collars post-treatment - no evidence of benefit 1
• Not identifying the correct canal before treatment - leads to treatment failure 1
• Moving too slowly during maneuvers - reduces effectiveness 1
• Failing to reassess treatment failures - most respond to repeat maneuvers 1

Special Populations

Patients with physical limitations (severe cervical stenosis, rheumatoid arthritis, cervical radiculopathy) may require: 1

• Modified approaches or specialized examination tables 1
• Referral to vestibular physical therapy 1
• Consider Brandt-Daroff exercises as alternative (though less effective) 1

Elderly patients warrant particular caution with any vestibular suppressant medications due to high fall risk 1, 3