What is the best approach for managing a patient with vertigo, possibly due to Benign Paroxysmal Positional Vertigo (BPPV)?

Medical Management of Vertigo (BPPV)

Perform the Epley maneuver immediately upon diagnosis—this is the definitive first-line treatment for posterior canal BPPV with 70-80% resolution after a single treatment, and do not prescribe vestibular suppressant medications like meclizine as they are ineffective for BPPV and cause significant adverse effects. 1, 2, 3

Diagnostic Approach

Confirm the diagnosis and identify the affected canal before treatment:

• Perform the Dix-Hallpike maneuver for posterior canal BPPV (accounts for 80-90% of cases): bring the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus 1, 2, 3
• If Dix-Hallpike is negative but BPPV is still suspected, perform the supine roll test to assess for lateral semicircular canal BPPV (10-15% of cases) 1, 2
• Do not order brain imaging or vestibular testing in patients who meet diagnostic criteria for BPPV without additional neurological signs 1, 3

Treatment Algorithm by Canal Type

Posterior Canal BPPV (80-90% of cases)

Perform the Epley maneuver immediately:

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° toward unaffected 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, 4, 5

Expected outcomes: 70-80% resolution after one treatment, 90-98% after repeat maneuvers if needed 2, 6, 5

Alternative: Semont (Liberatory) maneuver has comparable efficacy (94.2% resolution at 6 months) 2, 7

Horizontal Canal BPPV (10-15% of cases)

• Geotropic variant: Barbecue Roll (Lempert) maneuver (50-100% success) or Gufoni maneuver (93% success) 2
• Apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side) 2

Critical Post-Treatment Instructions

Patients can resume normal activities immediately—do not impose postprocedural restrictions as they provide no benefit and may cause unnecessary complications 1, 2, 3

Medication Management: What NOT to Do

Do not prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV treatment 1, 2, 3, 8

Rationale for avoiding these medications:

• No evidence of effectiveness as definitive treatment for BPPV 2, 3
• Cause significant adverse effects: drowsiness, cognitive deficits, increased fall risk (especially in elderly) 2, 3
• Interfere with central compensation mechanisms, potentially prolonging symptoms 3
• Decrease diagnostic sensitivity during Dix-Hallpike maneuvers 2

Limited exception: Consider vestibular suppressants only for short-term management (24-48 hours) of severe nausea/vomiting in severely symptomatic patients 2

Management of Treatment Failures

If symptoms persist after initial treatment (occurs in 13-26% of cases):

1. Reassess within 1 month with repeat Dix-Hallpike or supine roll test 1, 3
2. Perform additional repositioning maneuvers if test remains positive (achieves 90-98% success) 2, 6
3. Evaluate for canal conversion (occurs in 6-7% of cases)—the posterior canal may convert to lateral canal or vice versa 2
4. Check for multiple canal involvement (rare but possible) 2
5. Rule out coexisting vestibular pathology if symptoms occur with general head movements or spontaneously 2
6. Consider CNS disorders if atypical features present (abnormal cranial nerves, severe headache, visual disturbances) 2

Risk Assessment Before Treatment

Assess all patients for modifying factors:

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Increased fall risk (BPPV increases fall risk 12-fold, especially in elderly) 1, 2, 3

Contraindications requiring modified approach:

• Severe cervical stenosis or radiculopathy
• Severe rheumatoid arthritis or ankylosing spondylitis
• Morbid obesity
• Known cerebrovascular disease 2

For patients with contraindications: Consider Brandt-Daroff exercises (though less effective: 24% vs 71-74% success at 1 week) or refer to specialized vestibular physical therapy 2

Adjunctive Therapy

Offer vestibular rehabilitation therapy (VRT) as adjunctive therapy, not as substitute for repositioning maneuvers:

• Particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful repositioning 2, 3
• Reduces recurrence rates by approximately 50% 2
• Patients treated with repositioning plus VRT show significantly improved gait stability compared to repositioning alone 2

Self-Treatment Option

Teach self-administered Epley maneuver to motivated patients after at least one properly performed in-office treatment—64% improvement rate compared to 23% with Brandt-Daroff exercises 2

Patient Education

Counsel patients regarding:

• Impact of BPPV on safety and fall risk
• High recurrence rates (10-18% at 1 year, 30-50% at 5 years)
• Each recurrence should be treated with repeat repositioning (maintains same high success rates)
• Importance of follow-up within 1 month 1, 2, 3

Common Pitfalls to Avoid

• Prescribing meclizine or other vestibular suppressants as primary treatment—this is the most common error in ED management 9
• Ordering unnecessary brain imaging in patients meeting BPPV criteria without red flags 1, 3, 9
• Imposing postprocedural restrictions after repositioning maneuvers 1, 2
• Not performing the maneuver quickly enough—rapid movements are essential for effectiveness 2
• Failing to reassess patients who don't improve after initial treatment 1, 3
• Not checking for canal conversion when symptoms worsen or persist after treatment 2