Benign Paroxysmal Positional Vertigo

Terry D. Fife, M.D.


Semin Neurol. 2009;29(5):500-508. 

In This Article


Treatment of Posterior Canal BPPV

Treatment of BPPV is shown in Fig. 5 that depicts the canalith repositioning maneuver, sometimes referred to as the "Epley maneuver" or canalith repositioning maneuver. Fig. 6 illustrates the Semont maneuver, which is an effective alternative treatment method. Both maneuvers and variations of them are designed to clear calcium debris from the posterior semicircular canal by moving it back into the vestibule by the effects of gravity because the calcium carbonate crystals sink in the endolymph. Once the calcium carbonate crystals are back in the vestibule, they are absorbed within a period of days in most patients. If properly done, the canalith repositioning maneuver eliminates BPPV immediately in greater than 85% of patients.[7,24] Similar success has been reported with the Semont maneuver (Fig. 6). Patients that do not respond to canalith repositioning have calcium particles that are immobile or that are attached to the cupula. Benign paroxysmal positional vertigo that is disabling and refractory to all positioning treatments can be managed surgically, though this is rarely necessary.

Figure 5.

Canalith repositioning maneuver. Step 1: Seat the patient on a table positioned so they may be taken back to the head hanging position with the neck in slight extension. Stabilize the head with your hands and move the head 45 degrees toward the side you will test. Move the head, neck and shoulders together to avoid neck strain or forced hyperextension. Step 2: Observe for nystagmus and hold the position for ~10 seconds after it stops. Step 3: Keeping the head tilted back in slight hyperextension, turn the head ~90 degrees toward the opposite side and wait 20 seconds. Step 4: Roll the patient all the way on to his or her side and wait 10 to 15 seconds. Step 5: From this side-lying position, turn the head to face the ground and hold it there 10 to15 seconds. Step 6: Keeping the head somewhat in the same position, have them sit up then straighten the head. Hold on to the patient for a moment because some patients feel a sudden but very brief tilt when sitting up. REPEAT: After waiting 30 seconds or so, repeat the whole maneuver. If there is not paroxysmal nystagmus or symptoms during Dix-Hallpike positioning (Steps 1, 2) then there is a high likelihood of success.

Figure 6.

Semont liberatory maneuver. Step 1: Start with the patient sitting on a table or flat surface with head turned away from the affected side. Step 2: Quickly put the patient into the side-lying position, toward the affected side with the head turned up. Nystagmus will occur shortly after arriving at the side-lying position. Keep the patient here until at least 20 seconds after all nystagmus has ceased. Step 3: Quickly move the patient back up and through the sitting position so that he or she is in the opposite side-lying position with head facing down (head did not turn during the position change). Keep the patient in this position for ~30 seconds (some recommend up to 10 minutes). Step 4: At a normal or slow rate, bring the patient back up to the sitting position.

Benign paroxysmal positional vertigo is a mechanically based disorder best managed by a mechanical remedy. Vestibular suppressants such as meclizine or diazepam may have a role in premedicating those patients with severe motion sickness, but are generally not helpful for BPPV because the episodes are brief and because the therapeutic maneuvers are so immediate and effective.

Self-treatment of BPPV

Patients given instructions for self-administered canalith repositioning treatment at home show improvement that is superior to that seen on those given self-administered Brandt-Daroff exercises.[25] Home exercises seem to pose little risk for most patients, and may be a useful adjunct to treatment, but is probably somewhat less effective than treatment administered by an experienced clinician.[26]

Treating Lateral Canal BPPV

Lateral canal BPPV is often unresponsive to canalith repositioning designed to treat posterior canal BPPV,[17,27,28] but may respond to any of a variety of other maneuvers intended to move canaliths from the lateral canal into the vestibule. The best treatment for horizontal canal BPPV remains unclear. The most commonly used treatment in the published literature is the roll maneuver (Lempert maneuver or barbecue roll maneuver) (Fig. 7) or similar variations.[12,13,17,23,28–33] The effectiveness of the roll maneuver in treating lateral canal BPPV appears to be <75%,[13,33] although reported response rates vary from near 50% to almost 100%. An overview of some of the other treatments for horizontal canal BPPV are discussed elsewhere.[13,31] At this time, there is insufficient evidence to support the use of any particular maneuver over another for lateral canal BPPV treatment.[24]

Figure 7.

Lempert 360- (Barbeque) degree roll maneuver to treat horizontal canal BPPV. When the patient's head is positioned with the affected ear down, the head is then turned quickly 90 degrees toward the unaffected side (face up). A series of 90-degree turns toward the unaffected side is then undertaken sequentially until the patient has turned 360 degrees and is back to the affected ear-down position. From there, the patient is turned to the face-up position and then brought up to the sitting position. The successive head turns can be done in 15- to 20-second intervals even when the nystagmus continues. Waiting longer does no harm, but may lead to the patient developing nausea, and the shorter interval does not appear to detract from the effectiveness of the treatment.

The treatment of horizontal canal BPPV depends on knowing the affected side, which is not always obvious. If the horizontal canal BPPV occurs after treatment for posterior canal BPPV, then the affected ear is likely to be the same one that had been affected by the posterior canal BPPV. As mentioned earlier, the side with the strongest nystagmus from the supine head turning test (Fig. 4) is usually assumed to be the affected side. Nevertheless, in some cases the affected side is unclear, and one must simply choose one side.

Posttreatment Restrictions

Over the years there have been various recommendations, such as wearing a cervical collar or sleeping upright following treatments. A recent review found there was little difference in outcome between those given posttreatment restrictions and those receiving no instructions or restrictions.[24] At this point, evidence is lacking to recommend postmaneuver restrictions in patients treated with canalith repositioning therapies, although there is generally no associated harm associated with these instructions.


The most common complications include nausea, vomiting, fainting, and conversion to lateral canal BPPV during the course of treatment due to "canal switch" that occurs ~6% of the time,[27,34] underscoring the importance of recognizing the lateral canal variant of BPPV. Patients with unstable cervical spine injury or who may not safely have their head moved should have treatment deferred, but there are otherwise no contraindications.