What is the preferred initial approach for managing vertigo?

Preferred Management of Peripheral Vertigo

Canalith repositioning procedures (CRPs), specifically the Epley maneuver for posterior canal BPPV, are the definitive first-line treatment for peripheral vertigo, with success rates of approximately 80% after 1-3 treatments and 90-98% after repeat maneuvers if needed. 1

Initial Diagnostic Approach

The diagnosis must be established through bedside testing before initiating treatment:

• Perform the Dix-Hallpike test for posterior canal BPPV (accounts for 85-95% of cases), looking for characteristic torsional upbeating nystagmus 1
• Perform the supine roll test if Dix-Hallpike is negative but BPPV is suspected, to assess for lateral (horizontal) canal BPPV (10-15% of cases) 1
• Do NOT order imaging or vestibular testing unless the diagnosis is uncertain or additional symptoms unrelated to BPPV are present 1

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

• Execute the Epley maneuver as first-line treatment: patient sits upright with head turned 45° toward affected ear, rapidly lay back to supine head-hanging 20° position for 20-30 seconds, turn head 90° toward unaffected side, roll patient onto shoulder while maintaining head position, then return to sitting 1
• Alternative option: Semont (Liberatory) maneuver with 94.2% resolution at 6 months and 71% at 1 week 1
• Success rates: 80.5% negative Dix-Hallpike by day 7; patients have 6.5 times greater chance of symptom improvement compared to controls 1

Horizontal Canal BPPV (10-15% of cases)

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

Critical Post-Treatment Instructions

• Patients can resume normal activities immediately - postprocedural restrictions provide NO benefit and may cause unnecessary complications 1
• Reassess within 1 month to confirm symptom resolution 1

Medication Management: What NOT to Do

Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV. 1 Despite FDA approval of meclizine for vertigo 2, the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against their routine use because:

• No evidence of effectiveness as definitive treatment for BPPV 1
• Significant adverse effects: drowsiness, cognitive deficits, increased fall risk (especially in elderly), interference with central compensation mechanisms 1
• Decreased diagnostic sensitivity during Dix-Hallpike maneuvers 1

Limited exception: Vestibular suppressants may be considered ONLY for short-term management of severe nausea/vomiting in severely symptomatic patients refusing other treatment 1

Management of Treatment Failures

If symptoms persist after initial CRP, follow this reassessment protocol:

• Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV 1
• Perform additional repositioning maneuvers - repeat CRPs achieve 90-98% success rates 1
• Check for canal conversion - occurs in approximately 6% of cases (posterior to lateral or vice versa) 3, 1
• Evaluate for multiple canal involvement - rare but possible; initial treatment may have targeted wrong canal 1
• Consider coexisting vestibular pathology if symptoms are provoked by general head movements (not just positional changes) or occur spontaneously 3
• Rule out CNS disorders masquerading as BPPV if atypical features present - found in 3% of treatment failures 3

Adjunctive Vestibular Rehabilitation Therapy

• Offer VRT as adjunctive therapy, not as substitute for CRP, particularly for patients with residual dizziness, postural instability, or heightened fall risk after successful CRP 1
• VRT reduces recurrence rates by approximately 50% when added after successful repositioning 1
• Brandt-Daroff exercises are significantly less effective than CRP (24% vs 71-74% success rate at 1 week) and should not be first-line 1

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 rate compared to 23% with Brandt-Daroff exercises 1

Special Populations Requiring Modified Approach

Assess all patients before treatment for contraindications and risk factors 1:

• Cervical spine pathology (severe stenosis, radiculopathy) - consider Brandt-Daroff exercises instead 1
• Physical limitations (morbid obesity, severe rheumatoid arthritis, Down syndrome, Paget's disease) - may need specialized examination tables or modified approaches 1
• Elderly patients - particularly at risk for falls; BPPV increases fall risk 12-fold 1
• CNS disorders, impaired mobility, lack of home support - warrant specialized vestibular physical therapy referral 1

Common Pitfalls to Avoid

• Prescribing vestibular suppressants as primary treatment - delays compensation and provides no benefit for BPPV 1
• Imposing postprocedural restrictions - no evidence of benefit and may cause complications 1
• Failing to reassess after initial treatment - persistent symptoms may indicate canal conversion, multiple canal involvement, or coexisting pathology 3, 1
• Not moving patient quickly enough during maneuvers - reduces effectiveness 1
• Ordering unnecessary imaging in straightforward BPPV cases - wastes resources and delays treatment 1