What is the first‑line management of benign paroxysmal positional vertigo (BPPV)?

Management of Benign Paroxysmal Positional Vertigo (BPPV)

The first-line management of BPPV is immediate canalith repositioning procedures (CRP), specifically the Epley maneuver for posterior canal BPPV, performed at the bedside without any imaging, vestibular testing, or vestibular suppressant medications. 1, 2

Diagnostic Confirmation Before Treatment

• Perform the Dix-Hallpike maneuver by bringing the patient from upright to supine with the head turned 45° to one side and neck extended 20° with the affected ear down, looking for torsional upbeating nystagmus to diagnose posterior canal BPPV (which accounts for 80-90% of cases). 1, 2

• If the Dix-Hallpike is negative but BPPV is still 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 brain imaging or vestibular testing in patients who meet diagnostic criteria for BPPV without additional neurological signs inconsistent with BPPV. 1, 2, 3

First-Line Treatment by Canal Type

Posterior Canal BPPV (85-95% of cases)

• Perform the Epley maneuver immediately upon diagnosis, which achieves 70-80% resolution after a single treatment and 90-98% success with repeat maneuvers if needed. 2, 4

• Epley maneuver technique: Patient sits upright with head turned 45° toward the affected ear → rapidly lay 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 (nose pointing down) for 20-30 seconds → return to sitting position. 2

• Alternative: The Semont (Liberatory) maneuver has comparable efficacy with a 94.2% resolution rate at 6 months. 2

Horizontal Canal BPPV (10-15% of cases)

• For geotropic variant (nystagmus beating toward the ground): Use the Gufoni maneuver (93% success rate) or Barbecue Roll maneuver (50-100% success rate). 2

• Gufoni maneuver technique: From sitting, move patient to side-lying position on the unaffected side for 30 seconds → quickly rotate head 45-60° toward the ground and hold 1-2 minutes → return to sitting with head turned toward the unaffected shoulder. 2

• For apogeotropic variant (nystagmus beating away from the ground): Use the modified Gufoni maneuver with the patient lying on the affected side. 2

Critical Post-Treatment Instructions

• Patients can resume normal activities immediately after CRP without any postprocedural postural restrictions—these restrictions provide no benefit and may cause unnecessary complications. 1, 2, 3

What NOT to Do: Medication Management

• Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV—they are ineffective for definitive treatment and cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interference with central compensation mechanisms. 1, 2, 3, 5

• Vestibular suppressants may only be considered for short-term management (24-48 hours) of severe nausea/vomiting in severely symptomatic patients who refuse other treatment. 2

Risk Assessment Before Treatment

• Assess all patients for modifying factors including impaired mobility or balance, CNS disorders, lack of home support, and increased fall risk—BPPV increases fall risk 12-fold, especially in elderly patients. 2, 3

• Patients with contraindications (severe cervical stenosis, severe rheumatoid arthritis, significant vascular disease) may require modified approaches such as Brandt-Daroff exercises or referral to specialized vestibular physical therapy. 2

Management of Treatment Failures

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

• If symptoms persist after initial CRP, repeat the Dix-Hallpike or supine roll test—if positive, perform additional repositioning maneuvers (success rates reach 90-98% with repeat treatments). 2, 4

• Evaluate for canal conversion (occurs in 6-7% of cases), multiple canal involvement, or coexisting vestibular pathology. 2, 6

• Consider CNS disorders if atypical features are present, including: direction-changing nystagmus, downward-beating nystagmus during Dix-Hallpike, spontaneous nystagmus without provocation, or accompanying neurological signs. 2

Adjunctive Therapy

• 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 repositioning—VRT reduces recurrence rates by approximately 50% and improves gait stability. 2

Self-Treatment Option

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

Patient Education and Follow-Up

• Counsel patients regarding the impact of BPPV on safety and fall risk, high recurrence rates (10-18% at 1 year, 30-50% at 5 years), and the importance of follow-up within 1 month. 2, 3

• Each recurrence should be treated with repeat repositioning, which maintains high success rates. 2

Common Pitfalls to Avoid

• Delaying treatment creates a high-risk period for falls and injury—perform CRP immediately upon diagnosis. 2

• Ordering unnecessary imaging or vestibular testing in straightforward BPPV cases wastes resources and delays effective treatment. 1, 5

• Prescribing vestibular suppressants as primary therapy delays recovery, causes side effects, and interferes with central compensation. 3, 5

• Failing to reassess treatment failures within 1 month may miss persistent BPPV, canal conversion, or central causes requiring different management. 2, 3