Treatment of Benign Paroxysmal Positional Vertigo (BPPV)
Canalith repositioning procedures (CRPs), specifically the Epley maneuver for posterior canal BPPV, are the definitive first-line treatment with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers if needed. 1, 2
Primary Treatment by Canal Type
Posterior Canal BPPV (85-95% of cases)
The Epley maneuver is the gold-standard treatment, involving: sitting upright with head turned 45° toward the affected ear, rapidly laying back to supine head-hanging 20° position for 20-30 seconds, turning head 90° to opposite side, rolling onto side with nose pointing down, then returning to upright position 1, 3
The Semont (Liberatory) maneuver is an equally effective alternative with 94.2% resolution at 6 months, though the Epley shows superior 3-month outcomes 1, 3
Both maneuvers have comparable efficacy; choose based on clinician preference, patient mobility limitations, or failure of the previous maneuver 4, 5
Horizontal (Lateral) Canal BPPV (10-15% of cases)
For geotropic variant: Use the Barbecue Roll (Lempert) maneuver (50-100% success) or Gufoni maneuver (93% success) 1, 2
For apogeotropic variant: Use the Modified Gufoni maneuver (patient lies on affected side first) 1, 3
The Gufoni maneuver is easier to perform as it only requires identifying the side of weaker nystagmus, not necessarily determining which side is involved 5
Anterior Canal BPPV (rare, <5% of cases)
- Deep head hanging maneuvers can be performed without knowledge of the side involved, though evidence is weaker 5
Critical Post-Treatment Instructions
Do NOT impose postprocedural restrictions—patients can resume normal activities immediately. 1, 2, 3
Strong evidence shows that head elevation restrictions, sleep position limitations, and activity restrictions provide no benefit and may cause unnecessary complications 1, 3
Patients may experience mild residual symptoms for a few days to weeks after successful treatment 1
Medication Management: What NOT to Do
Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV. 1, 2, 3
Despite FDA approval of meclizine for "vertigo associated with diseases affecting the vestibular system," 6 there is no evidence these medications are effective as definitive treatment for BPPV 1
These medications cause drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interfere with central compensation mechanisms 1, 2
Limited exception: Consider short-term use only for severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 1
Treatment Efficacy Data
Single CRP achieves 80.5% negative Dix-Hallpike by day 7 1
Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20) 1
A single CRP is >10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 1
Immediate symptom resolution occurs in 85% of patients after first CRP 7
Management of Treatment Failures
If symptoms persist after initial treatment, repeat the diagnostic test (Dix-Hallpike or supine roll test) to confirm persistent BPPV. 8, 1
Systematic Reassessment Protocol:
Repeat CRP if diagnostic test remains positive—success rates reach 90-98% with additional repositioning maneuvers 8, 1, 2
Check for canal conversion (occurs in ~6% of cases): posterior canal BPPV may convert to lateral canal BPPV and vice versa 8, 1
Evaluate for multiple canal involvement—rarely, 2 semicircular canals may be simultaneously involved 8
Consider that initial treatment may have targeted the wrong canal—reassess for involvement of other semicircular canals 8
Rule out coexisting vestibular dysfunction if symptoms are provoked by general head movements (not just positional changes) or occur spontaneously 8
Consider CNS disorders masquerading as BPPV (found in 3% of treatment failures)—especially if atypical features are present 8
Refractory Cases:
- For treatment failures refractory to multiple CRPs, surgical plugging of the involved posterior semicircular canal or singular neurectomy has >96% success rate, though data quality precludes definitive recommendations 8
Self-Treatment Options
Self-administered CRP can be taught to motivated patients after at least one properly performed in-office treatment, with 64% improvement compared to only 23% with self-administered Brandt-Daroff exercises 1, 2, 3
Brandt-Daroff exercises are significantly less effective than CRP (24% vs 71-74% success rate at 1 week) and should be reserved for patients with physical limitations preventing CRP 1
Brandt-Daroff exercises require three times daily performance for two weeks to be effective 1
Special Populations and Risk Factors
Assess all patients 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, with three-quarters having fallen in the previous 3 months) 1
Patients with Physical Limitations:
Cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, or spinal issues may require modified approaches or Brandt-Daroff exercises instead of CRP 1
Specialized examination tables may be needed for patients with limited mobility 1
Follow-Up Protocol
Reassess patients within 1 month after initial treatment to confirm symptom resolution. 2, 3
If symptoms persist, repeat diagnostic testing and proceed with reassessment protocol outlined above 8, 1
Long-term recurrence occurs in approximately 30% of patients, with significantly higher rates in elderly patients or those with head trauma or history of vestibular neuropathy 7, 9
Common Pitfalls to Avoid
Ordering unnecessary imaging or vestibular testing when diagnostic criteria are met 2
Prescribing vestibular suppressants as primary treatment 1, 2, 3
Not performing exercises with sufficient frequency (Brandt-Daroff requires three times daily) 1
Failing to reassess after initial treatment period 1
Not moving the patient quickly enough during maneuvers, which reduces effectiveness 1
Coexisting Conditions
Patients with both BPPV and Meniere's disease have significantly lower treatment success rates and higher recurrence rates, requiring more aggressive follow-up and repeated treatments 3
- CRPs remain equally effective for resolving positional nystagmus, but complete symptom resolution is significantly less likely 3