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Benign Paroxysmal Positional Vertigo Treatment & Management

  • Author: John C Li, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: May 06, 2016

Medical Care

Treatment options include watchful waiting, vestibulosuppressant medication, vestibular rehabilitation, canalith repositioning, and surgery.

  • Watchful waiting: Since benign paroxysmal positional vertigo (BPPV) is benign and can resolve without treatment in weeks to months, some have argued that simple observation is all that is needed. Conversely, this involves weeks or months of discomfort and vertigo, with the danger of falls and other mishaps from the episodic vertigo spells (eg, patients who work on scaffolding may fall easily).
  • Vestibulosuppressant medication: This medication usually does not stop the vertigo. Although it may provide minimal relief for some patients, it does not solve the problem; it only masks the problem. Adverse effects of grogginess and sleepiness also complicate the issue of medication.
  • Vestibular rehabilitation: Vestibular rehabilitation is a noninvasive therapy that can have success after lengthy periods. Unfortunately, it causes repeated stimulation of vertigo while the patient is performing the therapeutic maneuvers. Patients can be instructed in Cawthorne exercises that seem to help by dispersing particles.
  • Canalith repositioning: Since the benefit-to-risk ratio is so high with canalith repositioning, it appears to be the obvious first choice among treatment modalities.
    • Particle repositioning is represented by two major maneuvers that developed simultaneously, yet independently, in the United States and France. These methods are the Epley maneuver and the Semont maneuver, and many minor variations of each of the methods exist. Both involve movements of the head to rearrange displaced particles. The Semont maneuver involves rapid and vigorous side-to-side head and body movements. The Epley maneuver is gentler and is described below. The canalith repositioning procedure (CRP) is a simple and noninvasive office treatment that is designed to cure BPPV in 1-2 sessions. See the image below. This therapy, in experienced hands, has a success rate of more than 95% for patients with BPPV.
      The patient is placed in a sitting position with t The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.
      See the list below:
      • Recently, research into multi-axial positioning devices that can perform canalith repositioning using 360 degree rotation in the proper plane of the semicircular canals has been conducted. The results are promising, but these devices need more study.
    • The Epley procedure is as follows (patient with right-sided BPPV in this example):
      • Starting position (sitting, head turned 45° toward ipsilateral side): The patient begins the procedure in a sitting position with the head turned toward the affected side. A mastoid bone oscillator is applied and held in position behind the affected ear by a headband to help agitate the particles so that they move more easily.
      • Position 1 (supine, head turned 45° toward ipsilateral side): The patient is reclined slowly to the supine position of the affected side. The rate is titrated to the point of no nystagmus and no symptoms. This usually takes approximately 30 seconds.
      • Position 2 (supine, 15° Trendelenburg, head turned 45° toward ipsilateral side): The patient is reclined further to the Dix-Hallpike position of the affected side. This usually takes 10 seconds. Another 20 seconds are spent in the Dix-Hallpike position with the affected ear down.
      • Position 3 (supine, 15° Trendelenburg, head turned 45° toward contralateral side): Next, the patient's head is turned slowly from position 3 toward the opposite side.
      • Position 4 (lying on side with contralateral shoulder down, head turned 45° below horizon toward contralateral side): The body is rolled so that the shoulders are aligned perpendicularly to the floor, affected ear up. The head is then turned farther so that the nose points 45° below the plane of the horizon. This usually takes another 40 seconds.
      • Position 5 (sitting, head turned at least 90-135° toward contralateral side): The patient is raised back to the sitting position with the head turned away from the affected side.
      • Ending position: Finally, the head is turned back to the midline. The mastoid bone oscillator is turned off, and the headband is removed.
    • A Dix-Hallpike test is performed immediately following the procedure. If nystagmus is observed, the procedure is repeated. After the procedure, the patient is instructed to avoid agitation of the head for approximately 48 hours while the particles settle and to return in 1 week for a follow-up examination.

The previously mentioned literature review by Anagnostou et al indicated that the anterior canal variant of BPPV can be successfully treated with the Epley and Yacovino maneuvers, as well as with various nonstandard maneuvers. The study, which included 31 citations, found a success rate of over 75% for each of these three types of maneuvers.[1]


Surgical Care

Surgery is usually reserved for those in whom CRP fails. It is not a first-line treatment because it is invasive and holds the possibility of complications such as hearing loss and facial nerve damage. Options include labyrinthectomy, posterior canal occlusion, singular neurectomy, vestibular nerve section, and transtympanic aminoglycoside application. All have a high chance of vertigo control.

Complete destruction of the affected inner ear is excessive, considering that only the posterior semicircular canal is involved. Therefore, the authors would not recommend labyrinthectomy or vestibular nerve section, except in the most extreme of cases.

Singular neurectomy, while theoretically a reasonable choice because it is directed at denervation of the offending posterior semicircular canal, is technically difficult and has only been mastered by a handful of surgeons. Furthermore, some of these patients have significant postoperative imbalance issues.

The most viable surgical option for patients who have failed CRP is posterior canal occlusion. The idea is to stop the benign positional vertigo by collapsing the posterior canal, immobilizing the movement of particles through the canal. This procedure is performed through a standard mastoidectomy approach. The offending posterior semicircular canal is isolated. The hard bone is drilled down with diamond burrs to expose the membranous labyrinth without spilling much perilymphatic fluid. The membranous labyrinth containing the endolymphatic fluid is compressed so that the flow of the length is disrupted. This keeps the particles from traveling through the endolymphatic space, thereby stopping the dizziness.

Success rates are in the 95th percentile range. Postoperative imbalance is not uncommon for a few weeks to months. This is typically treated with postoperative vestibular rehabilitation.



After CRP treatment, patients are instructed to avoid lying completely flat for 24-48 hours. Sleeping with the head elevated on a few pillows is recommended. Avoidance of jarring activities or gymnastic flips is recommended.

A correlation has been demonstrated between the head-lying side during sleep and the side affected by benign paroxysmal positional vertigo. Patients may want to adjust their sleeping positions accordingly to prevent recurrence.[6]

Contributor Information and Disclosures

John C Li, MD Private Practice in Otology and Neurotology; Medical Director, Balance Center

John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Neurotology Society, American College of Surgeons, American Medical Association, American Tinnitus Association, Florida Medical Association, North American Skull Base Society

Disclosure: Received consulting fee from Synthes Power Tools for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Auditory Society, The Triological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Michael E Hoffer, MD Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego

Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Received royalty from American biloogical group for other.


John Epley, MD Director, Portland Otologic Clinic

John Epley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Oregon Medical Association

Disclosure: Nothing to disclose.

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The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.
The patient is then brought back up to the sitting position.
Next, the patient is rolled 180° from the affected side to the opposite side. Note that the position of the head is 45° toward the affected side before the roll. The head winds up facing down, 180° away from the starting position.
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