What is Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

Benign Paroxysmal Positional Vertigo (BPPV) should be managed with the Epley maneuver as the first-line treatment, which has a high success rate of around 80% with only 1-3 treatments, as recommended by the American Academy of Otolaryngology—Head and Neck Surgery Foundation 1.

BPPV Overview

BPPV is a common inner ear disorder characterized by brief episodes of vertigo triggered by specific head movements. It is defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo 1. The condition occurs when calcium carbonate crystals (otoconia) become dislodged from their normal location and move into the semicircular canals, causing inappropriate fluid movement that signals false motion to the brain during certain head positions.

Diagnosis and Treatment

The diagnosis of BPPV is typically made through simple bedside testing, including the Dix-Hallpike test or supine roll test, which involves moving the patient's head into a position that triggers the vertigo symptoms 1. The Epley maneuver is a series of head positions that help relocate the displaced calcium crystals in the inner ear, and it can be performed under guidance initially, but also at home after proper instruction. During acute episodes, medications like meclizine (25mg every 4-6 hours as needed) or diazepam (2-5mg as needed) may provide temporary symptom relief but don't treat the underlying cause.

Management and Prevention

Patients with BPPV should avoid sudden head movements, particularly looking up or bending down, and should sleep with their head elevated on two pillows. Most BPPV cases resolve within weeks with proper treatment, though recurrence is common (about 30% within one year) 1. Observation, or watchful waiting, may be considered as an option in the management of BPPV, particularly in patients who are at low risk for falls or have mild symptoms, as the natural history of BPPV is usually one of eventual resolution of symptoms in most patients.

Key Points

• BPPV is a common inner ear disorder characterized by brief episodes of vertigo triggered by specific head movements.
• The Epley maneuver is the most effective first-line treatment for BPPV.
• Patients should avoid sudden head movements and sleep with their head elevated on two pillows.
• Most BPPV cases resolve within weeks with proper treatment, though recurrence is common.
• Observation may be considered as an option in the management of BPPV in patients who are at low risk for falls or have mild symptoms.

From the Research

BPPV Diagnosis and Treatment

• Benign paroxysmal positional vertigo (BPPV) is a common condition that causes acute vertigo or dizziness in patients presenting to an emergency department (ED) 2.
• The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver 2.
• The Epley maneuver is a safe and effective treatment for posterior canal BPPV, with a high success rate in resolving vertigo symptoms 3.

Epley Maneuver Efficacy

• The Epley maneuver has been shown to be more effective than other treatments, such as the Semont maneuver and Brandt-Daroff exercises, in resolving vertigo symptoms and converting a positive Dix-Hallpike test to a negative test 3, 4, 5.
• However, some studies have found that the Epley maneuver may not have an immediate therapeutic effect in treating PC-BPPV-cu, and that the Brandt-Daroff exercise may have an equivalent effect at 1 week 6.
• The Epley maneuver has been found to have a higher cure rate than the Semont maneuver and Brandt-Daroff exercises at 1 week and 3 months follow-up 4.

Comparison of Treatments

• A study comparing the efficacy of the Epley maneuver, Semont maneuver, and Brandt-Daroff exercises found that the Epley maneuver was more effective in resolving vertigo symptoms at 1 week and 1 month follow-up 5.
• Another study found that the Epley maneuver was more effective than the Brandt-Daroff exercise in treating PC-BPPV, but that the Semont maneuver was not significantly different from the Epley maneuver 4.
• The frequency of side effects and recurrence rates were not significantly different among the three physical therapy groups 5.

Predictors of Recurrence

• Duration of illness before self-treatment and age were found to be independent predictors of recurrence 5.
• Daily routine of self-treatment does not prevent the recurrence of PC-BPPV 5.