Treatment of Benign Paroxysmal Positional Vertigo (BPPV)
The Epley maneuver (canalith repositioning procedure) is the definitive first-line treatment for posterior canal BPPV, with an 80% success rate after 1-3 treatments, and should be performed immediately upon diagnosis without any postprocedural restrictions or vestibular suppressant medications. 1, 2
Diagnosis and Canal Identification
- Diagnose posterior canal BPPV using the Dix-Hallpike test, which provokes vertigo with torsional, upbeating nystagmus in approximately 80-90% of cases 1
- If the Dix-Hallpike test is negative but BPPV is still suspected, perform the supine roll test to assess for horizontal (lateral) canal BPPV, which accounts for 10-15% of cases 1
- The supine roll test involves the patient lying supine with the head turned rapidly 90° to each side, observing for horizontal nystagmus and vertigo 1
- Do not order imaging or vestibular testing unless the diagnosis is uncertain or there are additional symptoms unrelated to BPPV 1
Treatment Algorithm by Canal Type
Posterior Canal BPPV (85-95% of cases)
Perform the Epley maneuver immediately upon diagnosis with the following technique: 1, 2
- Patient sits upright with head turned 45° toward the affected ear
- Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
- Turn head 90° to opposite side and hold for 20-30 seconds
- Roll patient onto side with head rotated 45° toward ground, hold for 20-30 seconds
- Return patient to upright sitting position
Success rates are 80.5% by day 7 with just 1-3 treatments 1, 2
Patients treated with the Epley maneuver have 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20) 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
Alternative: The Semont (Liberatory) maneuver is also effective for posterior canal BPPV, with 94.2% resolution at 6-month follow-up and 71% symptom resolution at 1 week 1
Horizontal (Lateral) Canal BPPV (10-15% of cases)
For geotropic variant: Use the Barbecue Roll (Lempert) maneuver with success rates of 50-100%, involving rolling the patient 360 degrees in sequential 90° steps 1
Alternative for geotropic variant: The Gufoni maneuver achieves 93% success rate 1
- Patient moves from sitting to side-lying position on the unaffected side for 30 seconds
- Quickly turn head 45°-60° toward the ground and hold for 1-2 minutes
For apogeotropic variant: Use the Modified Gufoni maneuver 1
- Patient moves from sitting to side-lying position on the affected side for 30 seconds
- Quickly turn head 45°-60° toward the ground and hold for 1-2 minutes
Critical Post-Treatment Instructions
Do NOT impose postprocedural restrictions after canalith repositioning procedures—patients can resume normal activities immediately. 1, 2
- Strong evidence shows postprocedural restrictions provide no benefit and may cause complications 1, 2
- This is a common pitfall that should be avoided 2
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 primary treatment for BPPV 1
These medications cause significant adverse effects including: 1
- Drowsiness and cognitive deficits
- Increased risk of falls, especially in elderly patients
- Interference with central compensation in peripheral vestibular conditions
- Decreased diagnostic sensitivity during Dix-Hallpike maneuvers
Vestibular suppressants may only be considered for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 1
Treatment Failures: Reassessment Protocol
If symptoms persist after initial treatment, repeat the diagnostic test and perform additional repositioning maneuvers—success rates reach 90-98% with repeat treatments. 1, 2
When treatment fails, systematically evaluate for: 1, 2
- Persistent BPPV in the same canal requiring repeat maneuvers (90-98% success with additional treatments) 1, 2
- Canal conversion (switching from one type of BPPV to another), which occurs in 6-7% of cases 1
- Multiple canal involvement or bilateral BPPV requiring treatment of additional canals 1
- Coexisting vestibular pathology if symptoms are provoked by general head movements or occur spontaneously 1
- CNS disorders masquerading as BPPV, especially if atypical features are present (e.g., direction-changing nystagmus, vertical nystagmus without torsional component, severe imbalance) 1
Self-Treatment Options
Self-administered Epley maneuvers can be taught to motivated patients after at least one properly performed in-office treatment, achieving 64% improvement compared to only 23% with Brandt-Daroff exercises. 1, 4
- Each home Epley cycle involves holding each position for 20-30 seconds through 5 sequential steps 4
- Self-treatment is significantly more effective than Brandt-Daroff exercises 1, 4
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 (elderly patients are particularly at risk—9% of patients referred to geriatric clinics have undiagnosed BPPV, with three-quarters having fallen within the previous 3 months) 1
- Cervical spine pathology (severe cervical stenosis, radiculopathy, severe rheumatoid arthritis) may require modified approaches or Brandt-Daroff exercises instead 1, 2
Common Pitfalls to Avoid
- Ordering unnecessary imaging or vestibular testing when diagnostic criteria are met 2
- Prescribing vestibular suppressants as primary treatment 2
- Recommending postprocedural restrictions 2
- Failing to identify the affected canal and variant before treatment 1
- Not moving the patient quickly enough during the maneuver, which reduces effectiveness 1
- Not reassessing patients within 1 month if symptoms persist 1, 2