What are the management options for Benign Paroxysmal Positional Vertigo (BPPV)?

Management of Benign Paroxysmal Positional Vertigo (BPPV)

The Epley maneuver (canalith repositioning procedure) is the definitive first-line treatment for posterior canal BPPV, with success rates of 80-98% after 1-3 treatments, and vestibular suppressant medications should NOT be routinely prescribed as they are ineffective and cause harm. 1, 2

Diagnostic Approach

Initial Testing

• Perform the Dix-Hallpike maneuver by bringing the patient from upright to supine position with head turned 45° to one side and neck extended 20° with the affected ear down 1, 3
• A positive test shows torsional, upbeating nystagmus with vertigo, confirming posterior canal BPPV (85-95% of cases) 1, 2
• Repeat the maneuver with the opposite ear down if initially negative 1

If Dix-Hallpike is Negative

• Perform the supine roll test to assess for lateral (horizontal) semicircular canal BPPV (10-15% of cases) 1, 2
• This involves turning the patient's head rapidly 90° to each side while supine, observing for horizontal nystagmus 4

What NOT to Order

• Do NOT obtain brain imaging (CT or MRI) in patients meeting diagnostic criteria for BPPV without additional neurological symptoms 1, 3
• Do NOT order vestibular testing unless there are additional symptoms inconsistent with BPPV 1, 3

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

Primary Treatment: Epley Maneuver 1, 2, 5

The technique involves:

1. Patient sits upright with head turned 45° toward affected ear
2. Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
3. Turn head 90° to opposite side, hold 20-30 seconds
4. Roll patient onto side with nose pointing down, hold 20-30 seconds
5. Return patient to upright sitting position 2

Success rates: 80% after single treatment, 90-98% with repeat maneuvers 2, 4, 5

Alternative: Semont (Liberatory) Maneuver 2, 5

• Comparable efficacy to Epley (94.2% resolution at 6 months) 2
• Involves rapid side-to-side movements from affected to unaffected side 2
• Choose based on patient mobility limitations or clinician preference 6

Horizontal Canal BPPV (10-15% of cases)

For Geotropic Variant:

• Barbecue Roll (Lempert) Maneuver: Roll patient 360° in sequential 90° steps (50-100% success rate) 2, 3
• Alternative: Gufoni Maneuver (93% success rate) 2, 3

For Apogeotropic Variant:

• Modified Gufoni Maneuver: Patient lies on affected side, then turns head 45-60° toward ground 2

Critical Post-Treatment Instructions

Patients can resume normal activities immediately - postprocedural restrictions (head elevation, sleep position restrictions) provide NO benefit and may cause unnecessary complications 1, 2, 3

This is a strong recommendation based on high-quality evidence showing restrictions are ineffective 1, 3

Medication Management: What NOT to Prescribe

Do NOT routinely prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) for BPPV treatment 1, 2, 3

Why Medications Are Harmful:

• No evidence of effectiveness as definitive treatment for BPPV 2, 3
• Interfere with central compensation mechanisms, potentially prolonging symptoms 2, 3
• Increase fall risk, especially in elderly patients 2, 3
• Cause drowsiness and cognitive deficits 2
• Decrease diagnostic sensitivity during Dix-Hallpike testing 2

Limited Exception:

Vestibular suppressants may be considered only for short-term management (1-3 days) of severe nausea/vomiting in severely symptomatic patients refusing repositioning procedures 2, 3

Note: While meclizine is FDA-approved for "vertigo associated with diseases affecting the vestibular system," 7 this does NOT apply to BPPV, which is a mechanical disorder requiring physical repositioning, not medication 2, 3

Follow-Up and Treatment Failures

Reassessment Timeline

Reassess ALL patients within 1 month after initial treatment to document resolution or persistence of symptoms 1, 3, 4

If Symptoms Persist After Initial Treatment:

1. Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV 2, 4

2. Perform additional repositioning maneuvers - success rates reach 90-98% with repeat treatments 2, 4, 8

3. Check for canal conversion (occurs in 6-7% of cases) - posterior canal may convert to lateral canal or vice versa during treatment 2, 8

4. Evaluate for multiple canal involvement - bilateral BPPV or involvement of multiple canals may require sequential treatment 2, 8

5. Consider coexisting vestibular pathology if symptoms occur with general head movements or spontaneously (not just positional) 2

6. Rule out central nervous system disorders if atypical features present (vertical nystagmus, severe neurological symptoms, treatment-resistant cases) 2, 4

Self-Treatment Options

Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment 2, 3

• 64% improvement rate with self-administered CRP versus 23% with Brandt-Daroff exercises 2, 3
• Significantly more effective than observation alone 2

Brandt-Daroff exercises are less effective (24% success at 1 week versus 71-74% for repositioning maneuvers) but may be useful for patients with contraindications to standard maneuvers 2

Vestibular Rehabilitation Therapy (VRT)

Offer VRT as adjunctive therapy, not as substitute for canalith repositioning 2, 3

When to Consider VRT:

• Residual dizziness after successful repositioning 2
• Postural instability or heightened fall risk 2
• Patients who cannot tolerate standard repositioning maneuvers 2

VRT improves gait stability when combined with CRP compared to CRP alone 2

Special Populations and Contraindications

Assess ALL patients before treatment for modifying factors: 1, 2, 3

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Increased fall risk

Patients Requiring Modified Approaches:

• Severe cervical stenosis or radiculopathy - consider Brandt-Daroff exercises instead 2
• Morbid obesity - may need specialized examination tables 2
• Down syndrome, Paget's disease - modified positioning 2
• Recent retinal detachment or spinal cord injury - avoid head-hanging positions 2

High-Risk Populations:

Elderly patients warrant particular attention - 9% of geriatric clinic patients have undiagnosed BPPV, with three-quarters having fallen within 3 months 2

Common Pitfalls to Avoid

1. Ordering unnecessary imaging - brain imaging is not indicated for typical BPPV 1, 3, 9

2. Prescribing vestibular suppressants - delays recovery and increases fall risk 2, 3, 9

3. Imposing postprocedural restrictions - no evidence of benefit 1, 2, 3

4. Failing to repeat diagnostic testing after treatment - necessary to confirm resolution 2, 4

5. Not recognizing canal conversion - occurs in 6-7% of cases during treatment 2, 8

6. Assuming nystagmus during Epley indicates success - presence or absence of nystagmus during the maneuver does NOT predict treatment outcome 8

7. Missing post-treatment "otolithic crisis" - 19% of patients experience transient down-beating nystagmus and vertigo after treatment; counsel patients about this possibility to prevent falls 8

8. Treating the wrong canal - ensure accurate diagnosis before treatment 2

Patient Education

Counsel patients about: 1, 3, 4

• High recurrence rate (36% of patients) 5
• Increased fall risk, especially in elderly 2, 4
• Mild residual symptoms may persist for days to weeks after successful treatment 2
• When to return - if symptoms persist beyond 1 month or worsen 3, 4