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Benign Positional Vertigo: Treatment & Medication
Updated: Aug 24, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
If the history and physical examination are typical, no further evaluation is necessary, and the emergency physician may proceed with the modified Epley maneuver described below (see Media file 15 for a video demonstration). If the history and physical examination findings are atypical, consider other causes of positional vertigo, which may occur with tumor or infarcts in the posterior fossa.
Contraindications to performing the Epley maneuver include ongoing CNS disease (ie, stroke or transient ischemic attack [TIA]), unstable heart disease, severe neck disease (eg, rheumatoid arthritis) or history of cervical spine fracture or surgery, carotid bruit on examination indicating carotid stenosis, or body habitus preventing performance of the maneuver.
Further information on diagnosis and treatment guidelines and recommendations are available from the American Academy of Neurology and the American Academy of Otolaryngology-Head and Neck Surgery Foundation.2,4
- The goal of the Epley maneuver is to move the otoliths out of the posterior semicircular canal and back into the utricle where they belong.
- The success rate of the Epley maneuver is very high (approximately 85-90%). When it fails, it is the author's experience that it is being incorrectly applied to patients with vestibular neuritis or labyrinthitis.
- Epley maneuver, general guidelines5
- The head must be in the dependent (head-hanging) position for this maneuver to work. If the patient does not tolerate this position, put the gurney in the Trendelenburg position to simulate this head-hanging position.
- Maintain each position until the symptoms and nystagmus have disappeared or for at least 30 seconds.
- If the patient cannot tolerate the maneuver because of vomiting or severity of the vertigo, premedicate with a vestibular sedative, such as 25 mg IV promethazine (Phenergan).
- Epley maneuver steps
- Have the patient sit upright on the gurney with the head turned 45° to the affected side (this was predetermined by using the Hallpike test). Make sure the patient is sitting far enough back in the gurney so that the head will hang over the edge of the gurney when the patient is laid back. Make sure the guardrail on the opposite side has been lowered (the patient will eventually sit up so his or her legs overhang the edge of the gurney).
Epley maneuver. Move the patient back in the gurney such that when he lies down, his or her head will hang over the edge of the gurney. Emphasize to the patient to keep his or her eyes open during each position so that nystagmus can be observed. Lower the guardrails of the gurney on the opposite side from which the patient's head is turned.
- Place your hands on either side of the patient's head and guide the patient down with the head dependent (as in the Hallpike test).
Epley maneuver. Turn the patient's head 45° to the side that had the most prominent symptoms during the Hallpike test. In this example, the patient's head is turned 45° to the left. With both hands holding the patient's head, gently lay the patient down in the supine position with the head hanging over the edge of the bed. Note: Each maneuver does not need to be performed rapidly. The Epley maneuver is positional, not positioning.
- Rotate the head 90° to the opposite side with the patient's face upward and be sure to maintain the head-dependent position (head is hanging over the edge of the gurney).
- Ask the patient to roll onto his or her side while holding the head in this position and then rotate the head so that it is facing downward (tell the patient to look to the ground).
Epley maneuver. Ask the patient to turn onto his or her shoulder.
Epley maneuver. Guide the patient's head down so that he or she is looking at the ground. Again, wait for at least 30 seconds.
- Raise the patient to a sitting position while maintaining head rotation (This author finds that sitting the patient up so that he or she is sitting with his or her legs hanging over the edge of the gurney is easier. This is why the side guardrails need to be lowered before the procedure is started).
Epley maneuver. The patient's head needs to be regripped again. Then, the patient needs to sit up with the legs hanging over the side of the gurney (which is why the guardrails need to be lowered before the start of the procedure).
Epley maneuver. The patient is now sitting upright.
- Simultaneously rotate the head to a central position and move it 45° forward.
- The Semont maneuver (liberatory maneuver)
- This maneuver is primarily used in Europe. Although it can be used to treat classic posterior canal BPV, in the United States, it is usually reserved to treat the cupulolithiasis form of BPV (where the otoliths are not free-floating but instead are attached to the cupula of the posterior semicircular canal). Because of its somewhat violent nature (and the fact that most patients with BPV are elderly), the author does not advocate its use but includes it to be complete.
- As in the side-lying test, the patient sits on the edge of the gurney with the head turned opposite to the involved side. The patient is brought rapidly down onto his or her side (this serves to dislodge the otoliths off the cupula). The patient is then rapidly brought to the other side, maintaining the head in the same position (so the patient's face will be facing the gurney). The patient is then brought to the original sitting position. See Media file 16 for a video demonstration.
Consultations
Neurologic consultation is indicated for cases of positional vertigo and nystagmus that do not satisfy criteria for BPV. For example, downbeat nystagmus usually indicates a central cause. Although downbeat nystagmus can also indicate anterior canal involvement (which is benign), this is extremely rare.
Medication
Medical treatment for benign positional vertigo (BPV) is generally ineffective but may be used to lessen the symptoms.4 The natural history of BPV is to resolve with time as the otoliths eventually dissolve while in the semicircular canals.
The use of vestibular suppressants is based on the sensory conflict theory, in which sensory input is compared from different systems, and if a conflict exists, then nausea and vomiting result. Over time, habituation occurs. Several main neurotransmitters mediate these functions: GABA, acetylcholine, and histamine/serotonin.
Antihistaminic antiemetics
The antihistaminic antiemetics block the emetic response. For patients with severe vertigo or vomiting, intravenous promethazine (Phenergan) is the drug of choice; prochlorperazine (Compazine) is not very useful in this context. Meclizine is given orally and does not work fast enough to be effective acutely. Most antiemetics have anticholinergic activity as well.
Promethazine (Phenergan, Anergan, Prorex)
Antidopaminergic agent used to treat emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to brainstem reticular system. Also has cross reactivity with the cholinergic receptors.
Adult
25 mg IV/IM/PR q6h
Pediatric
<2 years: Contraindicated
<12 years: Not established
>12 years: 12.5 mg IV/IM/PR q6h
May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Documented hypersensitivity; comatose state or depressed CNS; children younger than 2 y (incidences of death due to respiratory depression)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma
Meclizine (Antivert, Antrizine, Dramamine)
Decreases excitability of middle ear labyrinth and blocks conduction in middle ear vestibular-cerebellar pathways. These effects are associated with relief of nausea and vomiting.
Adult
25-50 mg PO q12-24h; not to exceed 100 mg/d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
May increase toxicity of CNS depressants, neuroleptics, and anticholinergics
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in angle-closure glaucoma, prostatic hypertrophy, pyloric or duodenal obstruction, and bladder neck obstruction
Benzodiazepines
These agents block the GABA receptors and serve as the "brakes" to the system. Although they can be used acutely in the ED, they are not recommended for long-term use because they interfere with the process of vestibular rehabilitation.
Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has short time to onset and relatively long half-life. Depresses all levels of CNS, including limbic and reticular formation, probably through increased action of GABA, a major inhibitory neurotransmitter.
Adult
1-10 mg/d PO/IM/IV divided bid/tid
Pediatric
0.05 mg/kg/dose PO/IM/IV q4-8h
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAO inhibitors
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Anticholinergics
These agents block the conflict signal sites.
Scopolamine (Isopto, Scopace Tablet)
Blocks action of acetylcholine at parasympathetic sites in the smooth muscle, secretory glands, and CNS. Antagonizes histamine and serotonin action.
Transdermal scopolamine may be most effective agent for motion sickness. Use in the treatment of BPV is limited by slow onset of action.
Adult
0.5 mg topical patch
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
Antipsychotic effectiveness of phenothiazines may be decreased by coadministration with scopolamine; anticholinergic adverse effects may be increased by concurrent therapy and phenothiazine dosages should be adjusted as necessary; coadministration with tricyclic antidepressants may increase anticholinergic adverse effects (eg, dry mouth, constipation, urinary retention) because of additive effect (tricyclic antidepressants with less anticholinergic activity may be beneficial)
Documented hypersensitivity; primary glaucoma (including initial stages); pyloric obstruction; toxic megacolon; hepatic disease; paralytic ileus; severe ulcerative colitis; renal disease; obstructive uropathy; myasthenia gravis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly patients because of increased prevalence of glaucoma; large doses may suppress intestinal motility and precipitate or aggravate toxic megacolon; anticholinergics may aggravate hiatal hernia associated with reflux esophagitis; patients with prostatism can have dysuria and may require catheterization; use cautiously in patients with asthma or allergies; a reduction in bronchial secretions can lead to inspissation and formation of bronchial plugs
Dimenhydrinate (Dimetabs, Dramamine)
Mixture of 1:1 salt consisting of 8-chlorotheophylline and diphenhydramine. Believed to be useful, particularly in treatment of vertigo. Diminishes vestibular stimulation and depresses labyrinthine function through central anticholinergic effects. However, prolonged treatment may decrease rate of recovery of vestibular injuries.
Adult
25-50 mg PO/IV/IM/PR q6h
Pediatric
2-6 years: 12.5-25 mg PO q6-8h, not to exceed 75 mg/d; alternatively, 1.25 mg/kg or 37.5 mg/m2 IM qid, not to exceed 300 mg/d
6-12 years: 25-50 mg PO q6-8h, not to exceed 150 mg/d; alternatively, 1.25 mg/kg or 37.5 mg/m2 IM qid, not to exceed 300 mg/d
>12 years: Administer as in adults
Alcohol or other CNS depressants may have additive effect on dimenhydrinate; caution when administering concurrently with antibiotics that may cause ototoxicity; may mask ototoxic symptoms caused by certain antibiotics and irreversible damage may result
Documented hypersensitivity; do not administer to neonates; IV products may contain benzyl alcohol, which has been associated with fatal gasping syndrome in premature infants and low birth weight infants
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not treat severe emesis with antiemetic drugs alone; may contain either sulfites or tartrazine, which may cause allergic-type reactions in susceptible persons; may impede diagnosis of conditions, such as brain tumors, intestinal obstruction, and appendicitis; may obscure signs of toxicity from overdosage of other drugs
Sympathomimetic
These agents are useful in reversing soporific effects of vestibular sedatives.
Methylphenidate (Ritalin)
Piperidine derivative most commonly prescribed; efficacy has been demonstrated in randomized, double-blind, dose-response, and placebo-controlled trials. Stimulates cerebral cortex and subcortical structures.
Adult
10 mg PO bid/tid up to 60 mg/d
Pediatric
50 mg PO qd
Reduces effects of guanethidine and bretylium; toxicity of phenytoin, tricyclic antidepressants, warfarin, primidone, and phenobarbital may increase when administered concurrently with methylphenidate; MAO inhibitors increase toxicity of methylphenidate
Documented hypersensitivity; glaucoma; Tourette syndrome; motor tics; patients with agitation, tension, and anxiety
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in dementia, seizures, and hypertension
More on Benign Positional Vertigo |
| Overview: Benign Positional Vertigo |
| Differential Diagnoses & Workup: Benign Positional Vertigo |
 Treatment & Medication: Benign Positional Vertigo |
| Follow-up: Benign Positional Vertigo |
| Multimedia: Benign Positional Vertigo |
| References |
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References
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[Guideline] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Nov 2008;139(5 Suppl 4):S47-81. [Medline]. [Full Text].
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[Guideline] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. May 27 2008;70(22):2067-74. [Medline]. [Full Text].
Epley JM. Particle repositioning for benign paroxysmal positional vertigo. Otolaryngol Clin North Am. Apr 1996;29(2):323-31. [Medline].
Baloh RW. Dizziness and vertigo. In: Samuels MA, Feske S. Office Practice of Neurology. London: Churchill Livingstone; 1996:83-91.
Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. Aug 1980;106(8):484-5. [Medline].
Chang AK, Schoeman G, Hill M. A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Acad Emerg Med. Sep 2004;11(9):918-24. [Medline].
Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc. Jul 2000;75(7):695-700. [Medline].
Lempert T, Gresty MA, Bronstein AM. Benign positional vertigo: recognition and treatment. BMJ. Aug 19 1995;311(7003):489-91. [Medline].
Marill KA, Walsh MJ, Nelson BK. Intravenous Lorazepam versus dimenhydrinate for treatment of vertigo in the emergency department: a randomized clinical trial. Ann Emerg Med. Oct 2000;36(4):310-9. [Medline].
Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. Apr 1996;25(2):121-5. [Medline].
Troost BT, Patton JM. Exercise therapy for positional vertigo. Neurology. Aug 1992;42(8):1441-4. [Medline].
Further Reading
Keywords
benign positional vertigo, benign paroxysmal positional vertigo, BPV, vertigo, dizziness, dizziness symptoms, dizziness treatment, inner ear, Hallpike test, Epley maneuver, lightheadedness, canalolithiasis theory, otoliths, Brandt exercise, Daroff exercise
near-syncope, dysequilibrium, disequilibrium, orthostatic hypotension, vasovagal episode, neurocardiogenic syncope, disorder of thevestibular proprioceptive system, labyrinthitis, vestibular neuronitis, nystagmus, torsional nystagmus, rotatory nystagmus, dizzy, head-hanging maneuvers, labyrinthine disease, otoconia, psychophysiologic dizziness
