What is the appropriate management for benign paroxysmal positional vertigo in an otherwise healthy infant, child, or adult?

Management of Benign Paroxysmal Positional Vertigo (BPPV)

Perform the Epley maneuver immediately at the bedside for posterior canal BPPV—the most common variant—without ordering imaging, laboratory tests, or prescribing vestibular suppressant medications. 1, 2

Diagnostic Confirmation by Canal Type

Posterior Canal BPPV (85-95% of cases):

• Perform the Dix-Hallpike test by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20° below horizontal 1, 3
• A positive test shows torsional upbeating nystagmus with vertigo after a brief latency 1
• Treat immediately with the Epley maneuver if positive 1, 2

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

• If Dix-Hallpike is negative but BPPV is suspected, perform the supine roll test by turning the head rapidly 90° to each side while supine 1, 3
• Geotropic nystagmus (beating toward the ground) occurs in ~80% of horizontal canal cases 1
• Apogeotropic nystagmus (beating away from the ground) occurs in ~20% 1

First-Line Treatment by Canal Type

Posterior Canal BPPV: Epley Maneuver

The Epley maneuver achieves 80-93% resolution with a single treatment and 90-98% with repeat sessions. 1, 2

Standardized technique:

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

Critical execution points:

• Transitions must be performed relatively rapidly to maintain efficacy 2
• Hold each position for the full 20-30 seconds even if vertigo subsides 2
• Warn patients that intense vertigo, nausea, or falling sensation may occur but typically resolves within 60 seconds 2

Alternative for posterior canal: The Semont (liberatory) maneuver achieves 94.2% resolution at 6 months and is equally effective 1, 2

Horizontal Canal BPPV: Geotropic Variant

For geotropic horizontal canal BPPV, the Gufoni maneuver is preferred with a 93% success rate, superior to the Barbecue Roll (81%). 1

Gufoni maneuver technique:

1. From sitting, move patient to 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 unaffected shoulder 1

Barbecue Roll (Lempert) alternative:

• Continuous 360° roll from supine through prone, holding each position 15-30 seconds 1
• Success rates range 50-100% across studies 1

Horizontal Canal BPPV: Apogeotropic Variant

Modified Gufoni maneuver:

• Same technique as standard Gufoni but begin with patient lying on the affected side 1
• Evidence is limited to a single randomized trial 1

Post-Treatment Instructions

Patients may resume all normal activities immediately after any repositioning maneuver—no head-elevation, sleep-position, or activity restrictions are required or beneficial. 1, 2

• Post-procedural restrictions provide no therapeutic benefit and may cause unnecessary complications 1, 2
• Mild postural instability lasting up to 24 hours is common and self-limiting 1

Medication Management

Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV treatment. 1, 2

• These medications lack efficacy as definitive treatment for BPPV 1, 2
• They cause drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interfere with central vestibular compensation 1, 2

Limited exception: Short-term use may be considered only for severe nausea/vomiting in patients refusing other treatment or as prophylaxis 30-60 minutes before the maneuver in patients with prior severe nausea 1, 2

Management of Treatment Failures

Reassess within 1 month if symptoms persist. 1, 2

Repeat the diagnostic test (Dix-Hallpike or supine roll) to identify:

1. Persistent BPPV in the same canal: Repeat the repositioning maneuver—success rates reach 90-98% with additional treatments 1, 2

2. Canal conversion (6-7% of cases): Posterior canal may convert to lateral canal or vice versa during treatment 1, 2

   • Perform supine roll test if posterior canal treatment fails 1
   • Treat the newly affected canal with appropriate maneuver 1

3. Multiple canal involvement: Rare but may require sequential treatment of different canals 1

4. Coexisting vestibular pathology: Consider if symptoms occur with general head movements or spontaneously (not just positional) 1, 2

5. Central nervous system disorders masquerading as BPPV: Rule out if atypical features present 1, 2

Red Flags Requiring Urgent Neurological Evaluation

Do NOT attribute these findings to BPPV—they suggest central pathology:

• Nystagmus that changes direction without changing head position 1
• Downward-beating nystagmus during Dix-Hallpike 1
• Spontaneous nystagmus without provocation 1
• Severe neurological signs (cranial nerve deficits, severe headache, visual disturbances) 1
• Lack of symptom resolution after 2-3 properly performed repositioning attempts 1

Do NOT order imaging (CT/MRI) or vestibular testing unless these red flags are present. 1, 3

Special Populations Requiring Modified Approaches

Assess for contraindications before performing standard maneuvers: 1, 2

Absolute or relative contraindications:

• Severe cervical stenosis or radiculopathy 1, 2
• Severe rheumatoid arthritis or ankylosing spondylitis 1, 2
• Significant vascular disease 1, 2
• Severe kyphoscoliosis or limited cervical range of motion 1, 2
• Morbid obesity 1
• Spinal cord injury 1

For patients with contraindications:

• Consider Brandt-Daroff exercises (less effective: 24% vs 71-74% success at 1 week) 1
• Refer to specialized vestibular physical therapy 1, 2

Fall Risk Assessment and Counseling

BPPV increases fall risk 12-fold, particularly in elderly patients. 1, 3

• 53% of elderly BPPV patients report at least one fall in the preceding year 1
• 9% of patients referred to geriatric clinics have undiagnosed BPPV, with three-quarters having fallen within 3 months 1

Provide immediate counseling on:

• Home safety assessment 1
• Activity restrictions until BPPV resolves 1
• Need for supervision in high-risk patients 1

Do NOT delay treatment—the period between diagnosis and treatment is high-risk for falls. 1

Adjunctive Vestibular Rehabilitation Therapy

Offer vestibular rehabilitation as an adjunct (not substitute) to repositioning maneuvers for: 1

• Residual dizziness after successful repositioning 1
• Postural instability 1
• Heightened fall risk 1

Benefits of adding VRT:

• Reduces recurrence rates by approximately 50% 1, 2
• Improves gait stability compared to repositioning alone 1

Self-Treatment Options

Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment. 1

• Self-administered CRP: 64% improvement 1
• Self-administered Brandt-Daroff exercises: 23% improvement 1
• Teach self-treatment only after confirming the patient can perform it correctly 1

Recurrence Management

BPPV has high recurrence rates: 1, 2

• 10-18% at 1 year 1, 2
• 30-50% at 5 years 1, 2
• Estimated 15% per year overall 1

Each recurrence should be treated with repeat repositioning maneuver, which maintains 90-98% success rates. 1, 2

Educate patients to recognize recurrent symptoms and seek prompt repeat treatment. 1

Pediatric Considerations

The 2017 AAO-HNS guideline does not include pediatric patients (age <18 years) due to substantially smaller evidence base. 4

• For children with suspected BPPV, consider referral to pediatric otolaryngology or neurology 4
• Do not confuse BPPV with benign paroxysmal vertigo of childhood, which is a distinct migraine-related condition 4

Common Pitfalls to Avoid

1. Ordering unnecessary imaging: Brain imaging is not indicated for typical BPPV without red-flag neurological signs 1, 3, 5

2. Prescribing vestibular suppressants: These medications are ineffective for BPPV and cause harm 1, 2, 5

3. Imposing post-treatment restrictions: Activity limitations provide no benefit and may increase complications 1, 2

4. Failing to reassess treatment failures: Persistent symptoms require repeat diagnostic testing to identify canal conversion or other causes 1, 2

5. Not performing maneuvers rapidly enough: Slow transitions reduce efficacy 1, 2

6. Treating the wrong canal: Horizontal canal BPPV requires different maneuvers than posterior canal BPPV 1

7. Missing central causes: Atypical features mandate neurological evaluation, not repeated repositioning 1