What are the treatments for Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

Benign Paroxysmal Positional Vertigo (BPPV) is primarily treated with specific repositioning maneuvers, such as the Epley maneuver, which has a high success rate of around 80% with only 1-3 treatments 1. The Epley maneuver involves a series of head position changes that should be performed by a healthcare provider initially, though patients can learn to do it at home after proper instruction. The Semont maneuver and Brandt-Daroff exercises are alternative techniques that may also be effective. These maneuvers work by using gravity to guide the displaced otoconia (calcium crystals) from the semicircular canals back to the utricle where they belong. Some key points to consider in the treatment of BPPV include:

• The use of vestibular suppressant medications is not routinely recommended for treatment of BPPV, other than for the short-term management of autonomic symptoms, such as nausea or vomiting, in a severely symptomatic patient 1.
• Patients should avoid sudden head movements, sleeping with extra pillows to keep the head elevated, and getting up slowly from lying down positions during recovery to prevent triggering vertigo episodes.
• In rare cases of persistent BPPV, surgical options like posterior semicircular canal occlusion might be considered, but this is uncommon.
• Vestibular rehabilitation may be offered as an option for the treatment of BPPV, based on controlled observational studies and a balance of benefit and harm 1. Overall, the goal of treatment is to alleviate symptoms, improve quality of life, and reduce the risk of falls and other complications associated with BPPV.

From the Research

Treatments for BPPV

• The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers, including the Epley, Semont, and Gufoni's maneuvers 2.
• The Epley manoeuvre is a safe and effective treatment for posterior canal BPPV, with a high success rate in resolving vertigo symptoms 3, 4.
• Canalith repositioning manoeuvres (CRP) are effective in treating posterior canal (PC) and horizontal canal (HC) BPPV, with 91% of PC BPPV cases and 88% of HC BPPV cases being effectively treated in 2 manoeuvres or less 5.
• The choice of manoeuvre depends on the clinician's preferences, failure of the previous manoeuvre, or movement restrictions of the patient, as their efficacy is comparable 2.
• Chair-assisted treatment may be of help if available, and surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV cases 2.
• Repeated testing and treatment of BPPV within the same session is promoted as a safe and effective approach to the management of BPPV, with a low risk of canal conversion 5.
• Clinicians should be aware of the possibility of post-treatment otolithic crisis following the treatment of BPPV, and take necessary precautions to ensure patient safety 5.
• The Epley manoeuvre is comparable to other particle repositioning manoeuvres, such as the Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises 4.
• A practical approach for emergency physicians includes performing a bedside test (Dix-Hallpike test) and treating patients with a bedside positional (the Epley) maneuver, which can reduce resource utilization and improve patient-centered outcomes 6.