Treating benign paroxysmal positional vertigo

Drugs may relieve the nausea and vomiting associated with benign paroxysmal positional vertigo (BPPV) (see symptomatic treatment of acute vertigo), but do little for the vertigo. The vertigo is treated with particle repositioning manoeuvres (Epley manoeuvre, Semont manoeuvre) or exercise therapy (Brandt-Daroff exercises). These treatments displace the otoconia from the posterior semicircular canal into the utricular cavity. The Epley and Semont manoeuvres are equally effective. However, the Semont manoeuvre is usually easier to perform on patients with limited neck movement or a prominent cervical kyphosis.

If the original nystagmus is reproduced in the final head position of the manoeuvre, this usually means the treatment has been effective. If the nystagmus reverses direction in the final head position, this means that the otoconia may have fallen back into the posterior canal. If one particle repositioning manoeuvre (ie Epley or Semont) is not effective at the first visit, then at the next visit repeat it or try the other manoeuvre.

Avoid performing another Hallpike manoeuvre within 15 minutes of a particle repositioning manoeuvre (sometimes done to assess the response to treatment)—this is because of the risk of displacing the otoconia into the horizontal canal, causing horizontal canal BPPV. If the particle repositioning manoeuvre appears to be a success, the repeat Hallpike manoeuvre can be deferred to the next visit.

Clinicians who are not familiar with the Epley and Semont manoeuvres can prescribe the Brandt-Daroff exercises (performed at home). Alternatively, they can refer the patient to a physiotherapist with expertise in vestibular rehabilitation therapy.

Symptoms recur in 20 to 30% of cases. If so, teach the patient to perform the Epley or Semont manoeuvre at home, or advise them to continue the Brandt-Daroff exercises (the manoeuvres and exercises can be printed as patient handouts). Refer refractory cases for expert assessment.