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

From the Guidelines

Benign positional vertigo should be treated with a canalith repositioning procedure, such as the Epley maneuver, as initial therapy for patients with posterior canal BPPV, as recommended by the strongest and most recent evidence 1.

Diagnosis and Treatment

The diagnosis of benign positional vertigo (BPPV) involves a thorough medical history and physical examination, including the Dix-Hallpike maneuver to assess for posterior semicircular canal BPPV 1. If the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus, a supine roll test should be performed to assess for lateral semicircular canal BPPV 1.

Key Considerations

• Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo, and assess patients for factors that modify management, such as impaired mobility or balance, central nervous system disorders, and increased risk for falling 1.
• Radiographic imaging and vestibular testing are not recommended in patients who meet diagnostic criteria for BPPV, unless there are additional signs or symptoms that warrant further evaluation 1.
• Postprocedural postural restrictions are not recommended after canalith repositioning procedure for posterior canal BPPV 1.

Treatment Options

• The Epley maneuver, a series of head position changes, is an effective treatment for posterior semicircular canal BPPV, with a high success rate in resolving symptoms 1.
• Vestibular rehabilitation and observation with follow-up are also options for managing BPPV, although the evidence for these approaches is less strong than for the Epley maneuver 1.
• Medications like meclizine may help manage symptoms, but they do not treat the underlying cause of BPPV and are not recommended as routine treatment 1.

Outcome Assessment and Follow-up

• Clinicians should reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms 1.
• Patients with persistent symptoms should be evaluated for unresolved BPPV and underlying peripheral vestibular or central nervous system disorders 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults.

Meclizine is indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults, which includes benign positional vertigo. The recommended dosage is 25 mg to 100 mg daily, in divided doses 2. Common adverse reactions include drowsiness, dry mouth, headache, fatigue, and vomiting 2.

From the Research

Diagnosis of Benign Positional Vertigo

• Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that can be easily diagnosed and treated in primary care 3.
• The Dix-Hallpike test is a bedside test used to diagnose BPPV, and it is an easy, low-cost, and effective method for assessing the outcome of treatment in patients with BPPV 4.

Treatment of Benign Positional Vertigo

• Particle repositioning maneuvers (PRM) are the treatment of choice for BPPV and have a high success rate, with Epley's maneuver and barbecue roll being recommended for the treatment of posterior semicircular canal (PSC) and horizontal semicircular canal (HSC) BPPV, respectively 3.
• The Epley canalith repositioning procedure or Semont maneuver has a significantly higher efficacy rate in patients with BPPV than placebo procedures, but results must be evaluated at 30 days by Dix-Hallpike test 4.
• Alternated Epley and Semont maneuvers may be more effective than repetition of the same maneuver in treating posterior canal BPPV, with a higher success rate of 84.5% compared to repeated Semont (65.9%) or repeated Epley (70.3%) maneuvers 5.
• Both Epley's maneuver and Semont's maneuver are effective in treating post-canal BPPV, with similar success rates of 92% and 84%, respectively, and the choice of maneuver may depend on patient preference, clinician expertise, and other individual factors 6.

Management of Benign Positional Vertigo

• The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver, which can reduce resource utilization, ED length of stay, and use of ineffective medications 7.
• Patients with BPPV should be reviewed regularly, and repeated maneuvers can be performed if symptoms persist, with unresolving symptoms requiring tertiary evaluation 3.