Management of Benign Paroxysmal Positional Vertigo

A Randomized Controlled Trial

Regina R. Sacco, DPT, BA, BHSC; David B. Burmeister, DO; Valerie A. Rupp, RN, MSN, CRNP; Marna Rayl Greenberg, DO, MPH


J Emerg Med. 2014;46(4):575-581. 

In This Article

Abstract and Introduction


Background. Benign paroxysmal positional vertigo (BPPV) is a common presenting problem.

Objective. Our aim was to compare the efficacy of vestibular rehabilitation (maneuver) vs. conventional therapy (medications) in patients presenting to the emergency department (ED) with BPPV.

Methods. This was a prospective, single-blinded physician, randomized pilot study comparing two groups of patients who presented to the ED with a diagnosis of BPPV at a Level 1 trauma center with an annual census of approximately 75,000. The first group received standard medications and the second group received a canalith repositioning maneuver. The Dizziness Handicap Inventory was used to measure symptom resolution.

Results. Twenty-six patients were randomized; 11 to the standard treatment arm and 15 to the interventional arm. Mean age ± standard deviation of subjects randomized to receive maneuver and medication were 59 ± 12.6 years and 64 ± 11.2 years, respectively. There was no significant difference in mean ages between the two treatment arms (p = 0.310). Two hours after treatment, the symptoms between the groups showed no difference in measures of nausea (p = 0.548) or dizziness (p = 0.659). Both groups reported a high level of satisfaction, measured on a 0−10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 9 ± 1.5 and 9 ± 1.0, respectively; there was no significant difference in satisfaction between the two arms (p = 0.889). Length of stay during the ED visit did not differ between the treatment groups (p = 0.873). None of the patients returned to an ED for similar symptoms.

Conclusions. This pilot study shows promise, and would suggest that there is no difference in symptomatic resolution, ED length of stay, or patient satisfaction between standard medical care and canalith repositioning maneuver. Physicians should consider the canalith repositioning maneuver as a treatment option.


Vertigo is a common complaint of patients who seek care in the emergency department (ED).[1] Vertigo is a frequent symptom in the general population, with a 12-month prevalence of 5% and an incidence of 1.4% in adults; its prevalence rises with age and is about two to three times higher in women than in men.[2] Benign paroxysmal positional vertigo (BPPV) is characterized by brief periods of vertigo triggered by a change in the position of a person's head relative to gravity.[3] It is the most common disorder, accounting for one third of vestibular diagnoses in the general population.[4] It was first described by Barany in 1921 and was later described in more detail by Dix and Hallpike in 1952.[5,6]

It is common practice for ED physicians to treat these patients symptomatically with benzodiazepines, antihistamines, or anticholinergic medications.[7] The canalith repositioning maneuver was developed by Epley.[8] This repositioning maneuver is considered an effective treatment for BPPV.[9] However, many existing studies have used a sham/placebo in the comparator arm.[10,11,12,13,14]

We set out to compare the efficacy of vestibular rehabilitation vs. conventional therapy in ED patients who present with BPPV. In particular, we sought to evaluate the improvement of vertigo in patients diagnosed with BPPV in the ED, assess their disposition time, and compare patient satisfaction between those patients who receive standard care vs. those who received vestibular rehabilitation.