What is the diagnosis and treatment for benign paroxysmal vertigo (BPV)?

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Last updated: March 28, 2025 • View editorial policy

From the Guidelines

Benign paroxysmal positional vertigo (BPPV) should be diagnosed using the Dix-Hallpike maneuver and treated with a canalith repositioning procedure, such as the Epley maneuver, as initial therapy. This approach is based on the strongest and most recent evidence from the 2017 clinical practice guideline for BPPV 1. The diagnosis of BPPV involves identifying vertigo associated with torsional, upbeating nystagmus provoked by the Dix-Hallpike maneuver, which is a strong recommendation for diagnosing posterior semicircular canal BPPV.

Key Points for Diagnosis and Treatment

  • Diagnosis of posterior semicircular canal BPPV should be made when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 1.
  • The Dix-Hallpike test should be repeated with the opposite ear down if the initial maneuver is negative to diagnose lateral (horizontal) semicircular canal BPPV 1.
  • Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo, and assess patients for factors that modify management, such as impaired mobility or balance, central nervous system disorders, lack of home support, and/or increased risk for falling 1.
  • Radiographic imaging and vestibular testing should not be obtained in patients who meet diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging or testing 1.

Treatment Approach

  • Canalith repositioning procedures, such as the Epley maneuver, are strongly recommended as initial therapy for patients with posterior canal BPPV 1.
  • Postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV are not recommended 1.
  • Observation with follow-up may be offered as initial management for patients with BPPV, and vestibular rehabilitation may be offered in the treatment of BPPV 1, 2, 3.
  • Vestibular suppressant medications, such as antihistamines and/or benzodiazepines, should not be routinely used to treat BPPV 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. Recommended dosage: 25 mg to 100 mg daily, in divided doses. The diagnosis of benign paroxysmal vertigo (BPV) is not directly stated in the provided drug labels. The treatment for vertigo associated with diseases affecting the vestibular system, which may include BPV, is meclizine hydrochloride tablets with a recommended dosage of 25 mg to 100 mg daily, in divided doses 4.

  • Key points: + Meclizine is used to treat vertigo associated with vestibular system diseases. + The recommended dosage is 25 mg to 100 mg daily. + Meclizine should be used with caution due to potential side effects, such as drowsiness and anticholinergic action 4.

From the Research

Diagnosis of Benign Paroxysmal Vertigo (BPV)

  • The diagnosis of BPV is typically based on the patient's medical history and physical examination, including the Dix-Hallpike maneuver or the roll test 5, 6, 7.
  • The diagnosis can be confirmed by the presence of nystagmus (abnormal eye movements) and vertigo (a spinning sensation) during the Dix-Hallpike maneuver or the roll test 8, 9.

Treatment of Benign Paroxysmal Vertigo (BPV)

  • The primary treatment for BPV is the canalith repositioning procedure (CRP), which involves a series of maneuvers to move the calcium particles (otoconia) out of the affected semicircular canal 5, 6, 9.
  • Vestibular rehabilitation (VR) can be used as an adjunctive treatment to improve balance and reduce symptoms of vertigo 5, 6, 7, 8.
  • VR can be used alone or in combination with CRP, and has been shown to improve balance control, promote visual stabilization, and reduce the unpleasantness of vertigo symptoms 5, 6, 8.
  • Medications such as betahistine may also be used to treat BPV, but their effectiveness is still being studied 6, 9.
  • In some cases, surgery may be necessary to treat BPV, but this is typically reserved for severe cases that do not respond to other treatments 7.

Treatment Outcomes

  • Studies have shown that CRP is an effective treatment for BPV, with a high success rate in resolving vertigo symptoms 5, 6, 9.
  • VR has been shown to improve balance and reduce symptoms of vertigo, and can be used as a first-line treatment for BPV 5, 6, 7, 8.
  • The combination of CRP and VR may be more effective than CRP alone in some cases, especially in elderly patients 5, 6.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.