From the Guidelines
Benign Paroxysmal Positional Vertigo (BPPV) is primarily treated with repositioning maneuvers, such as the Epley maneuver, which has a high success rate of around 80% with only 1-3 treatments 1.
Treatment Overview
The Epley maneuver involves a specific sequence of head movements performed while sitting on a bed or examination table. For posterior canal BPPV (most common type), the patient turns their head 45 degrees toward the affected ear, quickly lies back with shoulders on the bed and head extended slightly over the edge, turns the head 90 degrees to the opposite side, rolls onto that shoulder, and finally returns to a sitting position. This sequence should be repeated three times daily until symptoms resolve for 24 hours.
Alternative Techniques
The Semont maneuver and Brandt-Daroff exercises are alternative techniques that can be effective in treating BPPV. Home-based treatments are often successful, but severe or persistent cases may require professional guidance.
Medications
Medications like meclizine (25mg every 4-6 hours as needed) can temporarily relieve vertigo symptoms but don't address the underlying cause. Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines 1.
Vestibular Rehabilitation
The clinician may offer vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV. This can be an option for patients who require additional support in managing their symptoms.
Outcome Assessment
Clinicians should reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms. Patients with persistent symptoms should be evaluated for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders 1.
Education
Clinicians should educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. This education can help patients manage their condition effectively and reduce the risk of falls and other complications.
From the Research
BPPV Treatment Overview
- BPPV is a common cause of vertigo that can be easily diagnosed and treated in primary care 2.
- 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 3.
Treatment Options
- Particle repositioning maneuvers (PRM) are the treatment of choice and have a high success rate, from 75% for multicanal to 95.8% for PSC, and to 100% for HSC and ASC involvement respectively 2.
- The Epley maneuver is a safe and effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomized controlled trials with relatively short follow-up 4.
- The choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient 5.
Treatment Outcomes
- Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham maneuver or control 4.
- Conversion from a positive to a negative Dix-Hallpike test significantly favored the Epley treatment group when compared to a sham maneuver or control 4.
- Adverse effects were infrequently reported, and there were no serious adverse effects of treatment 4.
Clinical Recommendations
- Repeated testing and treatment of BPPV within the same session is promoted as a safe and effective approach to the management of BPPV with a low risk of canal conversion 6.
- Vertigo and nystagmus throughout the Epley maneuver is not indicative of treatment success 6.
- Clinicians must remain vigilant and mindful of the possibility of post-treatment otolithic crisis following the treatment of BPPV 6.