What is the first line of treatment for Benign Paroxysmal Positional Vertigo (BPPV)?

First-Line Treatment for BPPV

The Epley maneuver (canalith repositioning procedure) is the definitive first-line treatment for posterior canal BPPV, which accounts for 85-95% of all BPPV cases, with an 80% success rate after 1-3 treatments and up to 90-98% success with repeat sessions if needed. 1, 2

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

• Perform the Epley maneuver immediately upon diagnosis - this involves a specific sequence: patient sits upright with head turned 45° toward affected ear, rapidly lay back to supine with head hanging 20° below horizontal for 20-30 seconds, turn head 90° toward unaffected side for 20 seconds, turn head another 90° requiring body roll to lateral position for 20-30 seconds, then return to sitting 1, 3
• The Semont maneuver is an alternative with comparable efficacy (94.2% resolution at 6 months, 71% at 1 week) if the Epley cannot be performed or fails 1, 4
• 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, 5

Horizontal Canal BPPV (10-15% of cases)

• For geotropic variant: use the Barbecue Roll (Lempert) maneuver (50-100% success) or Gufoni maneuver (93% success) 1, 2
• For apogeotropic variant: use the Modified Gufoni maneuver (patient lies on affected side) 1

Critical Post-Treatment Instructions

Patients can resume normal activities immediately after treatment - postprocedural restrictions provide NO benefit and may cause unnecessary complications. 1, 2, 3

• No head elevation requirements 2, 3
• No sleeping position restrictions 1, 2
• No activity limitations 2, 3

What NOT to Do: Medication Management

Do NOT routinely prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) - there is no evidence they work as definitive treatment for BPPV and they cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk, and interference with central compensation mechanisms. 1, 2, 3

• Vestibular suppressants may be considered ONLY for short-term management of severe nausea/vomiting in severely symptomatic patients refusing other treatment 1
• These medications decrease diagnostic sensitivity during Dix-Hallpike testing 1

Treatment Efficacy Data

• Patients treated with canalith repositioning have 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20) 1
• Success rate is 80.5% by day 7 after initial treatment 1, 2
• Repeat maneuvers achieve 90-98% cumulative success rates 1, 2, 3

When Treatment Fails: Reassessment Protocol

If symptoms persist after 1-2 weeks, repeat the diagnostic test (Dix-Hallpike or supine roll test) to confirm persistent BPPV before performing additional maneuvers. 1, 2, 3

• Canal conversion occurs in approximately 6-7% of cases (posterior may convert to lateral or vice versa) 1
• Evaluate for multiple canal involvement or bilateral BPPV 1, 2
• Rule out coexisting vestibular dysfunction if symptoms occur with general head movements or spontaneously 1
• Consider CNS disorders masquerading as BPPV if atypical features are present 1, 2

Self-Treatment Option

• Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment, with 64% improvement rate compared to 23% with Brandt-Daroff exercises 1, 2

Special Populations Requiring Modified Approach

Assess all patients before treatment for contraindications: 1, 2

• Severe cervical stenosis or radiculopathy - consider Brandt-Daroff exercises instead 1, 3
• Severe rheumatoid arthritis affecting cervical spine 1, 3
• Morbid obesity 1, 3
• Significant vascular disease 3
• Elderly patients warrant particular attention due to higher fall risk (9% of geriatric clinic patients have undiagnosed BPPV, with three-quarters having fallen within previous 3 months) 1

Vestibular Rehabilitation Therapy

• Offer VRT as adjunctive therapy only, NOT as substitute for canalith repositioning 1, 2
• Particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful treatment 1
• Patients treated with CRP plus VRT show significantly improved gait stability compared to CRP alone 1

Common Pitfalls to Avoid

• Do NOT order imaging or vestibular testing when diagnostic criteria are met through bedside testing alone 1, 2
• Movements between positions must be relatively rapid, particularly the transition from sitting to supine 3
• Maintain each position for the full 20-30 seconds even if symptoms resolve earlier 3
• Do NOT prescribe vestibular suppressants as primary treatment 1, 2, 3
• Do NOT recommend postprocedural restrictions 1, 2, 3