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

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

The canalith repositioning procedure (Epley maneuver for posterior canal BPPV) is the definitive first-line treatment and should be performed immediately upon diagnosis, with an 80% success rate after 1-3 treatments and 90-98% success after repeat maneuvers if needed. 1, 2, 3

Diagnosis and Canal Identification

Before treating, you must identify which canal is affected:

• Perform the Dix-Hallpike maneuver first to diagnose posterior canal BPPV (85-95% of cases), looking for torsional upbeating nystagmus when the patient is brought from upright to supine with head turned 45° to one side and neck extended 20° 1, 4

• If the Dix-Hallpike shows horizontal or no nystagmus, perform the supine roll test to assess for lateral (horizontal) canal BPPV (10-15% of cases) 1, 3

• Do not order imaging or vestibular testing when diagnostic criteria are met—this is unnecessary resource utilization that delays effective treatment 1, 2, 5

Treatment Algorithm by Canal Type

Posterior Canal BPPV (Most Common)

Perform the Epley maneuver immediately:

1. Patient sits upright with head turned 45° toward the affected ear 2, 4
2. Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds 2, 3
3. Turn head 90° to the unaffected side, hold 20-30 seconds 4
4. Turn head and body another 90° (face down position), hold 20-30 seconds 4
5. Return patient to sitting position 4

• Alternative: Semont (Liberatory) maneuver has comparable efficacy (94.2% resolution at 6 months) but requires more rapid movements 3, 6

Horizontal Canal BPPV

• For geotropic variant: Perform the Gufoni maneuver (93% success rate) or Barbecue Roll/Lempert 360° maneuver (75-90% effectiveness) 3, 4, 7

• For apogeotropic variant: Perform the modified Gufoni maneuver (patient lies on affected side first) 3, 4

Critical Post-Treatment Instructions

Patients can resume normal activities immediately—do NOT recommend postprocedural restrictions. 1, 2, 3

• Strong evidence shows postprocedural restrictions (head elevation, sleep restrictions) provide no benefit and may cause unnecessary complications 1, 2

• This is a common pitfall—many clinicians still recommend restrictions despite clear evidence against them 2

Medication Management: What NOT to Do

Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV. 1, 2, 3

• There is no evidence these medications are effective as definitive treatment for BPPV 3, 4

• They cause drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interfere with central compensation mechanisms 2, 3

• Only exception: Short-term use for severe nausea/vomiting in patients refusing repositioning procedures 3, 4

Treatment Failures and Reassessment

Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms. 1, 2

If symptoms persist, systematically evaluate for:

• Persistent BPPV in the same canal: Repeat the canalith repositioning procedure—success rates reach 90-98% with additional maneuvers 2, 3, 4

• Canal conversion (occurs in 6-7% of cases): The otoconia moved to a different canal during treatment, requiring repositioning for the newly affected canal 3, 8

• Multiple canal involvement or bilateral BPPV: Test all canals systematically 3, 8

• Coexisting vestibular pathology: Consider if symptoms occur with general head movements or spontaneously, not just with position changes 3

• Central nervous system disorders masquerading as BPPV: Especially if atypical features are present (pure vertical nystagmus, direction-changing nystagmus without latency, neurological signs) 1, 3

Self-Treatment Options

Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment, with 64% improvement compared to 23% with Brandt-Daroff exercises 2, 3

• This is significantly more effective than Brandt-Daroff exercises (single CRP is >10 times more effective than a week of Brandt-Daroff exercises) 2, 3

Vestibular Rehabilitation Therapy

Offer vestibular rehabilitation as adjunctive therapy, not as a substitute for canalith repositioning procedures. 3, 4

• Particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful CRP 3

• Patients treated with CRP plus vestibular rehabilitation show significantly improved gait stability compared to CRP alone 3

Special Populations Requiring Modified Approach

Before performing maneuvers, assess for modifying factors: 1, 2

• Severe cervical stenosis, cervical radiculopathy, or spinal cord pathology—consider Brandt-Daroff exercises instead 2, 3

• Severe rheumatoid arthritis limiting neck mobility 3

• Impaired mobility or balance, CNS disorders, lack of home support, increased fall risk 1, 2

• Elderly patients are at particularly high risk for falls (9% of geriatric clinic patients have undiagnosed BPPV, with three-quarters having fallen in the previous 3 months) 3

Common Pitfalls to Avoid

• Ordering unnecessary imaging or vestibular testing when diagnostic criteria are met 2, 5

• Prescribing vestibular suppressants as primary treatment instead of performing repositioning maneuvers 2, 3, 5

• Recommending postprocedural restrictions that have no evidence of benefit 1, 2

• Failing to reassess patients after initial treatment to confirm resolution 2, 4

• Missing canal conversions or multiple canal involvement in treatment failures 3, 8

• Not moving the patient quickly enough during maneuvers, which reduces effectiveness 3