Further Outpatient Care
Head exercise therapy (positional exercises of Brandt and Daroff) that promotes central accommodation may be helpful for BPV, although most patients have difficulty tolerating these maneuvers. The patient can perform the following therapy:
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Sit on the edge of the bed near the middle, with legs hanging down.
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Turn the head 45° to the right side. Quickly lie down on the left side, with the head still turned, and touch the bed with a portion of the head behind the ear.
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Maintain this position and every subsequent position for about 30 seconds.
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Sit up again.
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Quickly lie down to the right side after turning head 45° toward the left side.
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Sit up again.
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Do 6-10 repetitions, 3 times per day.
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If the patient becomes confused about the direction to turn his or her head, tell the patient his or her nose should always point toward the ceiling.
Further Inpatient Care
Patients with persistent vomiting or intractable vertigo may require admission for hydration and vestibular suppressant medication.
Surgical elimination of posterior canal function is restricted to rare cases of long-standing refractory benign positional vertigo (BPV).
Inpatient & Outpatient Medications
Meclizine is the most common outpatient medication. This medication is indicated for vertigo but should not be given for other categories of dizziness (near-syncope, dysequilibrium, or lightheadedness).
Deterrence/Prevention
Avoid provocative movements and limit activities.
Complications
No complications (eg, neck injury, vertebral dissection) other than vomiting have been reported from the use of the Epley maneuver.
Prognosis
Benign positional vertigo (BPV) tends to resolve spontaneously after several days or weeks. An Italian researcher removed the otoliths from an animal, placed them in a Petri dish full of endolymph, and noted that the otoliths dissolved in approximately 100 hours.
Patients may experience recurrences months or years later (if the otoliths got out once, they can do it again).
Variants range from a single, short-lived episode to decades of vertigo with only short remissions.
A study by Kim et al assessed patients who were discharged home from the ED with a diagnosis of isolated dizziness or vertigo and determined that stroke occurs in less than 1 in 500 patients within the first month. [7] Cerebrovascular risk factors should be considered for individual patients.
Patient Education
See the list below:
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For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Benign Positional Vertigo.
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Anatomy of the semicircular canals.
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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.
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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.
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Epley maneuver. The patient's head should be at 45° and hanging off the edge of the bed. Observe the patient's eyes and look for torsional nystagmus. Keep the patient in this position for at least 30 seconds or until the nystagmus or symptoms resolve.
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Epley maneuver. Because the patient's head will be turned 90° in the other direction, the physician needs to move to the head of the gurney and regrip the patient's head so that the fingers are pointing toward the patient's feet.
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Epley maneuver. Turn the patient's head 90° in the opposite direction (in this case, the patient's head is now facing to the right). Again, observe for nystagmus and hold this position for at least 30 seconds or until nystagmus or symptoms resolve.
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Epley maneuver. Close-up view of step shown in Media file 6.
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Epley maneuver. Ask the patient to turn onto his or her shoulder.
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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.
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Epley maneuver. Close-up of view shown in Media file 9.
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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).
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Epley maneuver. The patient is now sitting upright.
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Epley maneuver. Move the patient's head slightly forward. This completes the Epley maneuver. The maneuver may be performed multiple times.
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Hallpike test. In this example, the right posterior semicircular canal is being tested. Note that the head extends over the edge of the gurney. The thumb can be used to help keep the eyelids open since noting the direction of the nystagmus is important.
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Epley maneuver. In this example, the left posterior semicircular canal is being treated. In this clip, the maneuvers are performed quickly. In a real patient, each position should be held for at least 30 seconds or until resolution of the nystagmus and vertigo.
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Semont maneuver. Generally reserved for the cupulolithiasis form of benign positional vertigo, in which the otoliths are attached to the cupula of the semicircular canal. This maneuver has to be performed rapidly to be effective, and it is not recommended in elderly persons. In this example, the right posterior semicircular canal is being treated.
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Bar-b-que maneuver. This maneuver is used to treat horizontal canal benign positional vertigo. In this example, the right horizontal canal is being treated. Each position should be held at least 20-30 seconds.
