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

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

The canalith repositioning procedure (CRP), specifically the Epley maneuver for posterior canal BPPV, should be performed immediately upon diagnosis as first-line treatment, with an 80% success rate after 1-3 treatments and no need for imaging, medications, or post-treatment activity restrictions. 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, 3

• 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, 3

• Do not order imaging or vestibular testing when diagnostic criteria are met—normal medical imaging and laboratory testing cannot confirm BPPV. 1, 2

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

Perform the Epley maneuver immediately: 1, 2, 3

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

• Success rate: 80% after 1-3 treatments, increasing to 90-98% with repeat maneuvers if needed. 1, 3, 4

• Alternative option: Semont (Liberatory) maneuver has comparable efficacy with 94.2% resolution at 6 months and 71% at 1 week. 1, 5, 6

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, 3, 6

• For apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side). 1, 3

Critical Post-Treatment Instructions

Patients can resume normal activities immediately—do not impose postprocedural restrictions. 1, 2, 3

• Strong evidence shows postural restrictions provide no benefit and may cause unnecessary complications. 2, 7

• Mild residual symptoms (postural instability, lightheadedness) for a few days to weeks are common and self-limiting. 1

Medication Management: What NOT to Do

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

• There is no evidence these medications work as definitive treatment. 1, 2

• They cause significant adverse effects: drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interference with central compensation mechanisms. 1, 2

• Exception: Consider only for short-term management of severe nausea/vomiting in severely symptomatic patients. 1

Follow-Up and Treatment Failure Management

Reassess patients within 1 month after initial treatment to confirm symptom resolution. 1, 2, 3

If symptoms persist, repeat diagnostic testing and evaluate for: 1, 2, 3

• Persistent BPPV: Repeat CRP achieves 90-98% success rates. 1, 2, 4

• Canal conversion: Occurs in 6-7% of cases—particles move from one canal to another during treatment. 1, 8

• Multiple canal involvement: Rare but may require treatment of additional canals. 1, 8

• Coexisting vestibular pathology: If symptoms occur with general head movements or spontaneously. 1

• CNS disorders masquerading as BPPV: Especially if atypical features present (abnormal cranial nerves, severe headache, visual disturbances). 1, 3

Adjunctive Therapy Options

Vestibular Rehabilitation Therapy (VRT) should be offered as adjunctive therapy, not as substitute for CRP. 1, 2, 3

• Particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful CRP. 1, 3

• Reduces recurrence rates by approximately 50%. 1, 3

• Brandt-Daroff exercises are significantly less effective than CRP (24% vs 71-74% success rate at 1 week) and should not replace repositioning maneuvers. 1

Self-Treatment for Motivated Patients

• Self-administered Epley maneuver can be taught after at least one properly performed in-office treatment, with 64% improvement rate compared to 23% with Brandt-Daroff exercises. 1, 3

Special Populations Requiring Modified Approach

Assess all patients before treatment for contraindications and modifying factors: 1, 2, 3

• Severe cervical stenosis or radiculopathy
• Severe rheumatoid arthritis or ankylosing spondylitis
• Morbid obesity
• Known cerebrovascular disease
• Impaired mobility or balance
• Increased fall risk (BPPV increases fall risk 12-fold, especially in elderly) 1, 3

For patients with contraindications, consider Brandt-Daroff exercises or referral to specialized vestibular physical therapy. 1, 2

Understanding Recurrence Patterns

• BPPV has inherently high recurrence rates: 10-18% at 1 year, 30-50% at 5 years, estimated 15% per year. 1

• Each recurrence should be treated with repeat CRP, which maintains the same high success rates. 1, 4

• Higher recurrence rates occur in elderly patients, those with head trauma history, or history of vestibular neuropathy. 4

Common Pitfalls to Avoid

• Do not order unnecessary imaging or vestibular testing when diagnostic criteria are met. 2

• Do not prescribe vestibular suppressants as primary treatment. 1, 2

• Do not recommend postprocedural restrictions—they provide no benefit. 1, 2, 7

• Do not fail to reassess patients after initial treatment period. 1, 2

• Do not assume treatment failure if vertigo and nystagmus occur throughout the Epley maneuver—this is not indicative of treatment success or failure. 8

• Be vigilant for post-treatment "otolithic crisis" (down-beating nystagmus and vertigo) occurring in 19% of patients after the first or second consecutive Epley maneuver to prevent injurious falls. 8