What is the appropriate work‑up and treatment for benign paroxysmal positional vertigo (BPPV)?

BPPV Work-Up and Treatment

Diagnosis: Bedside Testing Only

Diagnose BPPV using the Dix-Hallpike maneuver for posterior canal involvement (80-90% of cases) or the supine roll test for lateral canal involvement (10-15% of cases)—no imaging or laboratory testing is needed. 1, 2

Diagnostic Maneuvers

• Perform the Dix-Hallpike test first: Bring the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus that confirms posterior canal BPPV 3, 2

• If Dix-Hallpike is negative but BPPV is still suspected, perform the supine roll test by turning the patient's head rapidly 90° to each side while supine, observing for horizontal nystagmus indicating lateral canal BPPV 3, 2

• Do NOT order brain imaging (CT/MRI) or vestibular testing in patients who meet diagnostic criteria for BPPV without additional neurological signs such as abnormal cranial nerves, severe headache, visual disturbances, or direction-changing nystagmus 1, 2

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

Perform the Epley maneuver immediately upon diagnosis—this achieves 70-80% resolution after a single treatment and 90-98% success with repeat maneuvers. 3, 2, 4

Epley Maneuver Steps 3, 2:

1. Patient sits upright with head turned 45° toward the affected ear
2. Rapidly lay patient back to supine head-hanging 20° position, hold 20-30 seconds
3. Turn head 90° toward the unaffected side, hold 20-30 seconds
4. Turn head and body another 90° (face-down position), hold 20-30 seconds
5. Return patient to sitting position

Alternative: The Semont (Liberatory) maneuver has comparable efficacy with 94.2% resolution at 6 months 2, 4

Lateral (Horizontal) Canal BPPV (10-15% of cases)

For geotropic variant (nystagmus beating toward the ground):

• Gufoni maneuver (93% success rate): Move patient from sitting to side-lying on the unaffected side for 30 seconds, then quickly turn head 45-60° toward the ground and hold 1-2 minutes 3
• Barbecue Roll maneuver (50-100% success rate): Roll patient 360° in sequential steps while supine 3, 4

For apogeotropic variant (nystagmus beating away from the ground):

• Modified Gufoni maneuver: Place patient side-lying on the affected side for 30 seconds, then turn head 45-60° toward the ground for 1-2 minutes 3

Critical Post-Treatment Instructions

Patients can resume normal activities immediately—do NOT impose postprocedural restrictions such as keeping the head upright or avoiding certain positions, as these provide no benefit and may cause unnecessary complications. 1, 3, 2

Medication Management: What NOT to Do

Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV—they are ineffective for definitive treatment and cause drowsiness, cognitive deficits, and increased fall risk. 1, 3, 2

• Vestibular suppressants may be considered only for short-term management (24-48 hours) of severe nausea or vomiting in severely symptomatic patients who refuse repositioning or require prophylaxis immediately before/after the maneuver 3, 2

Management of Treatment Failures

If symptoms persist after initial treatment, reassess within 1 month with repeat Dix-Hallpike or supine roll testing. 2, 4

When the diagnostic test remains positive, perform repeat repositioning—this achieves 90-98% success rates 3, 2

Evaluate for these specific causes of treatment failure 3, 4:

• Canal conversion (occurs in 6-7% of cases): Posterior canal converts to lateral canal or vice versa, requiring repositioning of the newly affected canal
• Multiple canal involvement: Bilateral BPPV or involvement of more than one canal simultaneously
• Coexisting vestibular pathology: Symptoms provoked by general head movements or occurring spontaneously suggest additional vestibular dysfunction
• Central nervous system disorders masquerading as BPPV: Red flags include direction-changing nystagmus, downward-beating nystagmus during Dix-Hallpike, spontaneous nystagmus without provocation, or accompanying neurological signs

Risk Assessment Before Treatment

Assess all patients for fall risk factors before initiating treatment—BPPV increases fall risk 12-fold, particularly in elderly patients. 3, 2

Evaluate for modifying factors including 3, 2:

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Physical limitations (severe cervical stenosis, rheumatoid arthritis, morbid obesity) that may require modified approaches or Brandt-Daroff exercises instead

Counsel patients and families on home safety assessment, activity restrictions, and need for supervision until BPPV resolves—do not delay treatment, as the period between diagnosis and treatment creates high risk for injury. 3

Adjunctive Therapy

Offer vestibular rehabilitation therapy (VRT) as adjunctive therapy, not as a substitute for repositioning maneuvers, particularly for patients with residual dizziness, postural instability, or heightened fall risk after successful repositioning. 3, 2

• VRT reduces recurrence rates by approximately 50% and improves gait stability compared to repositioning alone 3, 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. 3, 2

Recurrence Management

BPPV has high recurrence rates: 10-18% at 1 year and 30-50% at 5 years—educate patients to recognize recurrent symptoms and seek prompt repeat repositioning, which maintains the same high success rates. 3, 5

Common Pitfalls to Avoid

• Ordering unnecessary imaging or vestibular testing in patients with typical BPPV presentation 1, 2
• Prescribing vestibular suppressants instead of performing repositioning maneuvers 1, 3, 2
• Imposing postprocedural restrictions that have no evidence of benefit 1, 3, 2
• Failing to reassess patients within 1 month after initial treatment 2, 4
• Missing canal conversion or multiple canal involvement when initial treatment fails 3, 4
• Not performing the maneuver quickly enough, which reduces effectiveness 3