Treatment

Patients may be offered the option of observation or “watchful waiting” as initial management since BPPV is often a self limiting condition and the symptoms may subside or disappear within 6 months of onset (1,2).

• according to several studies the rate of spontaneous symptomatic resolution was between 15 to 85 % at one month
• patients may be advised to avoid provocative (vertigo-producing) positions or activities till the resolution of symptoms
• due to the longer duration of symptoms, patients may be exposed to an increased risk of falls and lost days of work when compared to other interventions (1)

There are two medical approaches to treatment:

• vestibular sedatives/anti-emetics
  • the symptoms of an acute vestibular episode can be treated with either
    • an anti-emetic (e.g. prochlorperazine or promethazine or cyclizine) or
    • vestibular sedatives (e.g. the calcium channel antagonist* cinnarizine (adult dose 30mg tds) or the histamine analogue betahistine)
    • during the first days of the illness (3)
  • although these vestibular suppressant medications are commonly used, there is no evidence in literature to suggest that these are effective in the treatment of BPPV or as a substitute for repositioning manoeuvres (1)
• particle repositional manoeuvres – the aim of this treatment is to redirect the otoconial particles back to the utricle (4)
  • office treatment
    • Epley manoeuver
    • Semont manoeuver (5)
  • home treatment
    • modified Epley manoeuver (2,6)
    • Brandt-Daroff exercises (5)

*Cinnarizine is an antihistamine and calcium channel blocker of the diphenylmethylpiperazine group

Patients should be reassessed within a month’s time to confirm the resolution of symptoms (1).

Surgical options:

• although now rarely done, surgery may be considered for patients with longstanding BPPV who have failed to respond to appropriate and repeated repositioning procedures (4)
• two possible surgical procedures for benign paroxysmal positional vertigo (BPPV) are:
  • singular neurectomy which deafferentates the posterior semicircular canal (PSCC)
  • occlusion of the PSCC which defunctions it

Reference:

• (1) Bhattacharyya N et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5 Suppl 4):S47-81
• (2) Benign paroxysmal positional vertigo.American hearing research foundation 2006
• (3) Pagarkar W, Davies R. Dizziness. Medicine 2004; 32 (9): 18-23.
• (4) Bronstein A. Benign Paroxysmal Positional Vertigo (BPPV):Diagnosis and Physical Treatment. ACNR 2005;5(3)
• (5) Walsh RM et al. Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Clinical Otolaryngology 1999; 24 (4): 316-323.
• (6) Swartz R. Treatment of vertigo. Am Fam Physician 2005;71:1115-22, 1129-30
• (7) Mayo Clinic Researchers Find Outpatient Therapy an Effective Correction to Patients With Vertigo. Mayo Foundation for Medical Education and Research. 2008