What are the treatment options for vertigo (benign paroxysmal positional vertigo)?

Treatment of Vertigo (BPPV)

The Canalith Repositioning Procedure (Epley maneuver) is the definitive first-line treatment for posterior canal BPPV, with 90-98% success rates, and should be performed immediately upon diagnosis without any medication. 1, 2

Diagnosis First

Before treating, confirm BPPV diagnosis:

• Posterior canal BPPV: Perform the Dix-Hallpike maneuver looking for characteristic rotatory nystagmus 1, 2
• Lateral canal BPPV: Perform the supine roll test 1, 2
• Posterior canal is the most common form, followed by lateral canal 2

Treatment Algorithm by Canal Involvement

For Posterior Canal BPPV (Most Common)

Perform the Epley maneuver immediately 1, 2:

1. Seat patient upright with head turned 45° toward affected ear 2
2. Rapidly move to supine position with head hanging 20° below horizontal 2
3. Turn head 90° to unaffected side 2
4. Turn head and body another 90° (face down position) 2
5. Return to sitting position 2

• No postprocedural restrictions are necessary after the maneuver 2
• Success rate: 90-98% when performed correctly 1, 2

For Lateral Canal BPPV

Use the Gufoni maneuver or barbecue roll maneuver 1, 2:

• Success rates: 86-100% 1, 2
• Choose based on your familiarity and patient tolerance 2

What NOT to Do

Do NOT routinely prescribe vestibular suppressant medications (like meclizine) for BPPV treatment 2, 3:

• Medications do not address the underlying mechanical cause 3
• They may delay central compensation 1
• Meclizine may cause drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 3

Exception: Meclizine 25-100 mg daily may be considered ONLY for short-term management of severe nausea or vomiting associated with acute vertigo 2, 4, but never as primary treatment 2

Follow-Up and Treatment Failures

Reassess within 1 month to confirm symptom resolution 1, 2, 3:

If symptoms persist, evaluate for:

• Canal conversion (occurs in ~6% of cases) - requires repositioning for the newly affected canal 1, 2
• Multiple canal involvement 2
• Coexisting vestibular conditions (Ménière's disease, vestibular neuritis) 2
• Central nervous system disorders mimicking BPPV 2, 3

For persistent BPPV after multiple repositioning attempts:

• Repeat the appropriate maneuver for the affected canal 2
• Consider vestibular rehabilitation therapy as adjunctive treatment 1, 2
• For truly refractory cases (rare), surgical canal plugging has >96% success rates 2

Adjunctive Treatment Options

Vestibular Rehabilitation Therapy (VRT) may be offered 1, 2:

• Initially less effective than repositioning maneuvers, but long-term effectiveness approaches that of repositioning 1
• Particularly beneficial for elderly patients, potentially decreasing recurrence rates 1
• Can be home-based with initial instruction 1
• Brandt-Daroff exercises are significantly less effective than Epley (25% vs 80.5% resolution at 7 days) 2

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers - this is the most common error 2
• Failing to reassess patients after initial treatment 2
• Missing canal conversions or multiple canal involvement 2
• Using vestibular suppressants as primary treatment - they do not address the mechanical cause 2, 3