What is the recommended treatment for benign paroxysmal positional vertigo (BPPV)?

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

Perform a canalith repositioning procedure immediately upon diagnosis—specifically the Epley maneuver for posterior canal BPPV or the Gufoni maneuver for horizontal canal BPPV—without ordering imaging, vestibular testing, or prescribing medications. 1, 2

Diagnostic Confirmation Before Treatment

Identify which semicircular canal is affected:

• Perform the Dix-Hallpike maneuver first, as posterior canal BPPV accounts for 85-95% of cases 1, 2

  • Look for torsional upbeating nystagmus with 5-20 second latency that resolves within 60 seconds 3
  • The patient is brought from upright to supine with head turned 45° to one side and neck extended 20° 2

• If Dix-Hallpike is negative but BPPV is suspected, perform the supine roll test for horizontal canal involvement (10-15% of cases) 1, 2

  • Geotropic nystagmus (beating toward the ground) occurs in ~80% of horizontal canal cases 1
  • Apogeotropic nystagmus (beating away from ground) accounts for ~20% 1

First-Line Treatment by Canal Type

Posterior Canal BPPV (85-95% of cases)

Epley Maneuver (Canalith Repositioning Procedure):

1. Position 1: Patient seated upright, head turned 45° toward the affected ear 1
2. Position 2: Rapidly lay patient back to supine with head hanging 20° below horizontal; hold 20-30 seconds 1
3. Position 3: Turn head 90° toward the unaffected side; hold 20 seconds 1
4. Position 4: Rotate head an additional 90° (requiring body roll to lateral decubitus, nearly face-down); hold 20-30 seconds 1
5. Position 5: Return patient to upright seated position 1

Success rates: 80% after 1-3 treatments, increasing to 90-98% with repeat maneuvers 1, 2

Alternative: The Semont (Liberatory) maneuver achieves 94.2% resolution at 6 months and is comparable in efficacy to the Epley 1, 4

Horizontal Canal BPPV – Geotropic Variant (8-12% of cases)

Gufoni Maneuver (preferred—93% success rate):

1. From sitting, move patient to straight side-lying position on the unaffected side for ~30 seconds 1
2. Quickly rotate head 45-60° toward the ground; hold 1-2 minutes 1
3. Return to sitting with head turned toward the left shoulder until upright 1

Alternative: Barbecue Roll (Lempert 360° roll) achieves 50-100% success but is more complex 1, 4

Horizontal Canal BPPV – Apogeotropic Variant (2-3% of cases)

Modified Gufoni Maneuver:

• Same three-step sequence as standard Gufoni, but begin with patient side-lying on the affected side 1, 3

Critical Post-Treatment Instructions

Patients may resume normal activities immediately—no restrictions. 1, 2

• Post-procedural head-elevation, sleep-position, or activity restrictions provide no benefit and may cause unnecessary complications 1, 2
• Strong evidence demonstrates these restrictions are ineffective 1

Medication Management: Do NOT Prescribe Vestibular Suppressants

Avoid meclizine, antihistamines, and benzodiazepines as primary treatment for BPPV. 1, 2

• These medications have no evidence of effectiveness for treating BPPV 1, 2
• They cause significant adverse effects: drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interference with central compensation 1
• They decrease diagnostic sensitivity during Dix-Hallpike testing 1

Exception: Consider vestibular suppressants only for short-term management of severe nausea/vomiting in severely symptomatic patients refusing repositioning 1

Assessment of Fall Risk Before Treatment

Evaluate all patients for modifying factors:

• Impaired mobility or balance 1, 2
• CNS disorders 1, 2
• Lack of home support 1, 2
• BPPV increases fall risk 12-fold; ~53% of elderly patients with BPPV report falling in the preceding year 1, 3

Provide immediate fall-risk counseling: home safety assessment, activity restrictions, and need for supervision until BPPV resolves 1

Follow-Up and Management of Persistent Symptoms

Reassess within 1 month after initial treatment. 1, 2

If symptoms persist:

1. Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV 1, 2
2. Perform repeat repositioning maneuver—achieves 90-98% success 1, 2
3. Check for canal conversion (occurs in 6-7% of cases)—posterior may convert to lateral or vice versa 1, 3
4. Evaluate for multiple canal involvement (rare but possible) 1
5. Rule out coexisting vestibular dysfunction if symptoms occur with general head movements or spontaneously 1

Red flags requiring urgent evaluation for central causes:

• Nystagmus that changes direction without head position change 1
• Downward-beating nystagmus during Dix-Hallpike 1
• Spontaneous nystagmus without provocation 1, 3
• Lack of resolution after 2-3 repositioning attempts 1
• Neurological signs: cranial nerve deficits, severe headache, visual disturbances 1, 3

Adjunctive Therapy Options

Vestibular Rehabilitation Therapy (VRT):

• Offer as adjunct (not substitute) to repositioning maneuvers 1, 2
• Particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful repositioning 1, 2
• Reduces recurrence rates by approximately 50% 1, 2
• Patients treated with CRP plus VRT show significantly improved gait stability compared to CRP alone 1

Self-administered Epley maneuver:

• Can be taught to motivated patients after at least one properly performed in-office treatment 1, 2
• 64% improvement rate vs. 23% with Brandt-Daroff exercises 1, 2

Brandt-Daroff exercises:

• Less effective than repositioning maneuvers (24% vs. 71-74% success at 1 week) 1
• Consider for patients with physical limitations preventing standard maneuvers 1
• Must be performed three times daily for effectiveness 1

Special Populations Requiring Modified Approach

Contraindications to standard repositioning maneuvers:

• Severe cervical stenosis or radiculopathy 1, 2
• Severe rheumatoid arthritis or ankylosing spondylitis 1
• Severe kyphoscoliosis or limited cervical range of motion 1
• Morbid obesity, Down syndrome, Paget's disease, retinal detachment, spinal cord injuries 1

For these patients: Consider Brandt-Daroff exercises or refer to specialized vestibular physical therapy 1, 2

Common Pitfalls and Caveats

• Do not delay treatment between diagnosis and repositioning—this creates a high-risk period for falls 1
• Do not assume treatment failure after a single maneuver—90-98% of persistent cases respond to additional attempts 3
• Do not order routine imaging or vestibular testing unless atypical neurological features are present 1, 2
• Do not rush to surgical intervention—most treatment-resistant cases represent missed canal conversion or multiple-canal involvement, not true canal obstruction 3
• Expect high recurrence rates: 10-18% at 1 year, 30-50% at 5 years 1—educate patients to recognize symptoms and seek prompt repeat repositioning 1
• Post-treatment "otolithic crisis" (transient down-beating nystagmus and vertigo) can occur in ~19% of patients after the first or second Epley maneuver 5—this is self-limiting but requires fall precautions 5