What is the treatment for Benign Paroxysmal Vertigo (BPV)?

From the Guidelines

Benign paroxysmal positional vertigo (BPV) is primarily treated with the Epley maneuver, a series of head movements that help reposition displaced calcium crystals in the inner ear, as recommended by the most recent clinical practice guideline update 1. The Epley maneuver involves a series of specific head movements that can be performed at home after proper instruction or by a healthcare provider.

• Patients should sit on a bed with their head turned 45 degrees toward the affected side,
• quickly lie back with their head hanging slightly off the edge,
• maintain this position for 30 seconds,
• then turn their head 90 degrees to the opposite side for another 30 seconds,
• before rolling onto that side and sitting up slowly. This maneuver is effective because it moves the displaced otoconia (calcium crystals) from the semicircular canals back to the utricle where they belong, thus restoring normal inner ear function. Medications like meclizine (25mg every 4-6 hours as needed), dimenhydrinate (50mg every 4-6 hours), or promethazine (12.5-25mg every 4-6 hours) may provide temporary symptom relief but don't address the underlying cause, and their routine use is not recommended 1. Vestibular rehabilitation exercises can help the brain compensate for balance disturbances, and may be offered to patients as part of their treatment plan 1. During acute episodes, patients should avoid sudden head movements, sit or lie down when symptoms occur, and gradually resume normal activities as symptoms subside. Most cases resolve within weeks with proper treatment, though recurrence is possible, with a reported recurrence rate of 5% to 13.5% at 6-month follow-up 1. Patient education is also an important aspect of treatment, and should include information on the diagnosis, treatment options, and risk of recurrence, as well as counseling on fall prevention and home safety 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The treatment of Benign Paroxysmal Vertigo (BPV) is supported by the FDA drug label, as meclizine is indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults, which includes BPV.

• The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
• Meclizine should be used with caution due to potential side effects such as drowsiness and anticholinergic action 2.

From the Research

Treatment Options for Benign Paroxysmal Positional Vertigo (BPV)

• The Epley maneuver and barbecue roll are recommended for the treatment of posterior semicircular canal (PSC) and horizontal semicircular canal (HSC) BPV, respectively 3.
• Particle repositioning maneuvers (PRM) have a high success rate, ranging from 75% to 100% for different types of BPV 3.
• The choice of maneuver depends on the clinician's preferences, failure of previous maneuvers, or movement restrictions of the patient 4.
• Chair-assisted treatment and surgical canal plugging may be considered in selected cases 4.

Efficacy of Treatment Options

• The Epley maneuver has a high success rate, with 95.8% of patients with PSC-BPV experiencing relief after treatment 3.
• The modified Epley maneuver has been shown to be more effective than the traditional Epley maneuver in improving the single repositioning success rate and reducing the canal switching rate for PC-BPPV 5.
• Repeated testing and treatment of BPV within the same session is a safe and effective approach to management, with a low risk of canal conversion 6.

Clinical Recommendations

• Clinicians should be vigilant and mindful of the possibility of post-treatment otolithic crisis following the treatment of BPV 6.
• Patients should be reviewed regularly, and repeated maneuvers can be performed as needed 3.
• Unresolving symptoms require tertiary evaluation 3.
• The primary evidence-based treatment strategy for BPV should be physical therapy through maneuvers 4.