What is the treatment for Benign Paroxysmal Positional Vertigo (BPPV)?

Treatment of BPPV

The Epley maneuver (canalith repositioning procedure) is the first-line treatment for posterior canal BPPV and should be performed immediately upon diagnosis, with an 80% success rate after 1-3 treatments. 1, 2

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

• Epley Maneuver is the primary treatment, involving a series of head and body movements to reposition displaced otoconia from the semicircular canal back into the vestibule 1, 2
• The technique involves: patient sitting upright with head turned 45° toward the affected ear, then rapidly laying back to a supine head-hanging 20° position for 20-30 seconds, followed by sequential head and body turns 1
• Success rate is 80.5% by day 7, with patients having 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20) 1, 2
• Semont Maneuver (Liberatory Maneuver) is an alternative with comparable efficacy, showing 94.2% resolution at 6-month follow-up and 71% at 1 week 1
• A single Epley maneuver is more than 10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47) 1, 3, 4

Horizontal Canal BPPV (10-15% of cases)

• For geotropic variant: Barbecue Roll Maneuver (Lempert 360° roll) is first-line with 50-100% success rates, or Gufoni Maneuver with 93% success rate 1, 2
• For apogeotropic variant: Modified Gufoni Maneuver (patient lies on affected side) 1, 2

Critical Post-Treatment Instructions

Do NOT impose postprocedural restrictions—patients can resume normal activities immediately. 1, 2

• Strong evidence shows postprocedural restrictions provide no benefit and may cause complications 2
• 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

• There is no evidence these medications are effective as definitive treatment 1
• They cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 1, 2
• They interfere with central compensation in peripheral vestibular conditions 1
• Limited exception: May consider short-term use only for severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 1

Treatment Failures: Reassessment Protocol

If symptoms persist after initial treatment (occurs in ~20% of cases initially, though repeat maneuvers achieve 90-98% success): 1, 2

• Repeat the diagnostic test (Dix-Hallpike or supine roll test) to confirm persistent BPPV 1, 2
• Perform additional repositioning maneuvers—repeat CRPs achieve 90-98% success rates 1, 2
• Check for canal conversion (occurs in 6-7% of cases during treatment) 1, 3
• Evaluate for multiple canal involvement or bilateral BPPV 1, 2
• Consider coexisting vestibular conditions if symptoms are provoked by general head movements or occur spontaneously 1
• Rule out CNS disorders if atypical features are present 1, 2

Self-Treatment Options

Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment. 1, 3

• Self-Epley achieves 64% improvement compared to only 23% with Brandt-Daroff exercises 1, 3
• Each cycle involves holding each position for 20-30 seconds through 5 sequential steps 3
• Brandt-Daroff exercises are less effective (24% vs 71-74% success rate at 1 week for repositioning maneuvers) but may be appropriate for patients with physical limitations such as cervical stenosis or severe rheumatoid arthritis 1, 2

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 (particularly important in elderly—9% of patients referred to geriatric clinics have undiagnosed BPPV, with three-quarters having fallen within the previous 3 months) 1
• Cervical spine pathology (cervical stenosis, severe rheumatoid arthritis, radiculopathies) may require modified approaches or alternative exercises 1, 2

Common Pitfalls to Avoid

• Ordering unnecessary imaging or vestibular testing when diagnostic criteria are met with bedside testing 1, 2
• Prescribing vestibular suppressants as primary treatment 1, 2
• Recommending postprocedural restrictions 1, 2
• Not moving the patient quickly enough during maneuvers, which reduces effectiveness 1
• Failing to reassess patients after initial treatment if symptoms persist 1, 2
• Not recognizing that BPPV has a high recurrence rate (36-45% of patients experience recurrence) 5, 4