What is the recommended treatment for a patient with Benign Paroxysmal Positional Vertigo (BPPV)?

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

Perform the canalith repositioning procedure (CRP) immediately upon diagnosis—specifically the Epley maneuver for posterior canal BPPV—without ordering imaging, vestibular testing, or prescribing medications. 1, 2, 3

Diagnostic Confirmation Before Treatment

• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV (85-95% of cases), looking for torsional upbeating nystagmus when bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°. 1, 2

• If the Dix-Hallpike is negative but BPPV is suspected, perform the supine roll test to assess for lateral (horizontal) semicircular canal BPPV, which accounts for 10-15% of cases. 1, 2

• Do not order imaging or vestibular testing unless there are atypical neurological signs such as abnormal cranial nerves, severe headache, or visual disturbances. 1, 2, 3

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

• Perform the Epley maneuver immediately with the following steps: 1, 2, 3

  • Patient sits upright with head turned 45° toward the affected ear
  • Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
  • Turn head 90° toward the unaffected side and hold for 20-30 seconds
  • Roll patient onto their side while maintaining head position
  • Return patient to upright sitting position

• Success rate is 80% after 1-3 treatments, increasing to 90-98% with repeat maneuvers if needed. 1, 2, 3

• Alternative option: The Semont (Liberatory) maneuver has a 94.2% resolution rate at 6 months. 1

Horizontal Canal BPPV (10-15% of cases)

• For geotropic variant: Perform the Barbecue Roll (Lempert) maneuver (50-100% success rate) or Gufoni maneuver (93% success rate). 1, 2

• For apogeotropic variant: Perform the modified Gufoni maneuver (patient lies on affected side). 1

Critical Post-Treatment Instructions

• Patients can resume normal activities immediately—postprocedural postural restrictions provide no benefit and may cause unnecessary complications. 1, 2, 3

• Do not prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment, as there is no evidence of effectiveness and they cause drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients. 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

Treatment Efficacy Data

• A single CRP is more than 10 times more effective than a week of Brandt-Daroff exercises (OR 12.38; 95% CI 4.32-35.47). 1, 3

• Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20). 1, 3

• Performing repositioning as soon as possible after symptom onset reduces recurrence rates significantly (19.7% vs 45.8% when delayed beyond 24 hours). 4

Follow-Up and Treatment Failure Management

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms. 1, 2, 3

• If symptoms persist after initial treatment, repeat the diagnostic test to confirm persistent BPPV and perform additional repositioning maneuvers—repeat CRPs achieve 90-98% success rates. 1, 2, 3

• Evaluate for the following if treatment fails: 1, 2

  • Canal conversion (occurs in approximately 6-7% of cases)
  • Multiple canal involvement
  • Coexisting vestibular pathology
  • CNS disorders masquerading as BPPV (especially with atypical features)

• In 91% of posterior canal cases, effective treatment occurs in 2 maneuvers or less; bilateral or multiple canal involvement requires more treatments. 5

Adjunctive Therapy Options

• Offer Vestibular Rehabilitation Therapy (VRT) as adjunctive therapy, not as a substitute for CRP, particularly for patients with residual dizziness, postural instability, or heightened fall risk after successful CRP. 1, 2, 3

• VRT reduces recurrence rates by approximately 50% and improves gait stability compared to CRP alone. 1, 2

• 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, 3

  • Severe cervical stenosis or radiculopathy
  • Severe rheumatoid arthritis or ankylosing spondylitis
  • Morbid obesity
  • Severe kyphoscoliosis or limited cervical range of motion

• For patients with contraindications, consider Brandt-Daroff exercises (performed three times daily) or referral to specialized vestibular physical therapy. 1

• Elderly patients warrant particular attention as BPPV increases fall risk 12-fold, and 9% of patients referred to geriatric clinics have undiagnosed BPPV, with three-quarters having fallen within the previous 3 months. 1, 2

Common Pitfalls to Avoid

• Do not order unnecessary imaging or vestibular testing when diagnostic criteria are met. 3

• Do not prescribe vestibular suppressants as primary treatment—they are ineffective and interfere with central compensation mechanisms. 1, 2, 3

• Do not recommend postprocedural restrictions—strong evidence shows they provide no benefit. 1, 2, 3

• Do not assume vertigo and nystagmus throughout the Epley maneuver indicates treatment success—this is not a reliable marker. 5

• Remain vigilant for post-treatment otolithic crisis (down-beating nystagmus and vertigo), which occurs in 19% of patients after the first or second consecutive Epley maneuver, to prevent injurious falls. 5