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-Specific Treatment Algorithm

Posterior Canal BPPV (85-95% of cases)

• Perform the Epley maneuver immediately when the Dix-Hallpike test provokes torsional, upbeating nystagmus 1, 2
• The technique involves: patient sitting upright with head turned 45° toward the affected ear, rapidly moving to supine position with head hanging 20° below horizontal for 20-30 seconds, turning head 90° to unaffected side, rotating head and body another 90° (face down position), then returning to sitting 2, 4
• Success rate is 80.5% by day 7, with patients having 6.5 times greater chance of symptom improvement compared to controls 2, 3
• A single Epley maneuver is more than 10 times more effective than a week of Brandt-Daroff exercises 2, 3

Horizontal (Lateral) Canal BPPV (10-15% of cases)

• Perform the supine roll test if the Dix-Hallpike shows horizontal or no nystagmus 1, 3
• For geotropic variant: use the Gufoni maneuver (93% success rate) or Barbecue Roll maneuver (50-100% success rate) 2, 3, 4
• For apogeotropic variant: use the modified Gufoni maneuver (patient lies on affected side first) 2, 3

Critical Post-Treatment Instructions

Do NOT impose any postprocedural restrictions after canalith repositioning procedures. 1, 2, 3

• Strong evidence demonstrates that postprocedural restrictions provide no benefit and may cause unnecessary complications 2, 3
• Patients can resume normal activities immediately 2, 3

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 2, 3
• These medications cause drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interfere with central compensation mechanisms 2, 3
• Consider vestibular suppressants ONLY for short-term management of severe nausea/vomiting in patients refusing other treatment 3, 4

Management of Treatment Failures

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 diagnostic test and perform additional repositioning maneuvers (90-98% success rate with repeat treatments) 2, 3, 4
• Canal conversion (occurs in 6-7% of cases): The posterior canal may convert to lateral canal or vice versa during treatment 2, 3, 5
• Multiple canal involvement: Rare but may require treatment of more than one canal 3, 4
• Coexisting vestibular dysfunction: Consider if symptoms occur with general head movements or spontaneously 3
• Central nervous system disorders: Rule out if atypical features are present (e.g., pure vertical nystagmus, direction-changing nystagmus without latency) 2, 3

Alternative and Adjunctive Treatment Options

Vestibular Rehabilitation Therapy

• May be offered as adjunctive therapy (NOT as substitute for canalith repositioning) for patients with residual dizziness, postural instability, or heightened fall risk after successful treatment 3, 4
• Patients treated with canalith repositioning plus vestibular rehabilitation show significantly improved gait stability compared to repositioning alone 3

Self-Administered Treatment

• Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment 2, 3
• Self-administered canalith repositioning is significantly more effective (64% improvement) than self-administered Brandt-Daroff exercises (23% improvement) 2, 3

Brandt-Daroff Exercises

• Significantly less effective than canalith repositioning (24-25% vs 71-80.5% success rate at 1 week) 3, 4
• May be considered for patients with physical limitations preventing standard maneuvers (severe cervical stenosis, rheumatoid arthritis, cervical radiculopathy) 2, 3
• Performed three times daily: rapidly move to side-lying position with head rotated 45° facing upward, hold for 30 seconds after vertigo stops, then rapidly move to opposite side-lying position 3

Special Populations Requiring Modified Approach

Assess ALL patients before treatment for modifying factors: 1, 2

• Impaired mobility or balance 1, 2
• Central nervous system disorders 1, 2
• Lack of home support 1, 2
• Increased fall risk (particularly important in elderly patients, where 9% of those referred to geriatric clinics have undiagnosed BPPV, and three-quarters have fallen within the previous 3 months) 3

Contraindications or need for modified approaches: 3

• Severe cervical stenosis or radiculopathy 2, 3
• Severe rheumatoid arthritis 2, 3
• Morbid obesity 3
• Retinal detachment 3
• Spinal cord injuries 3

Common Pitfalls to Avoid

• Do NOT order imaging or vestibular testing in patients who meet diagnostic criteria for BPPV in the absence of additional signs/symptoms inconsistent with BPPV 1, 2, 6
• Do NOT rely on medications instead of performing repositioning maneuvers 4, 6
• Do NOT fail to reassess patients after initial treatment 3, 4
• Do NOT miss canal conversions or multiple canal involvement during follow-up 3, 4, 5
• Do NOT assume treatment success based solely on presence or absence of nystagmus during the maneuver—the definitive marker is a negative Dix-Hallpike or supine roll test on reassessment 5
• Be vigilant for post-treatment otolithic crisis (down-beating nystagmus and vertigo occurring in 19% of patients after the first or second Epley maneuver) to prevent injurious falls 5

Surgical Options for Refractory Cases

• Canal plugging may be considered for same-canal, same-side intractable severe BPPV refractory to multiple canalith repositioning procedures 7
• Success rates exceed 96% for surgical canal plugging 4