Gordon H. Sun, MD, MS


April 20, 2017

Treatment Options for BPPV

The two initial options for management of posterior canal BPPV are CRPs and observation. The AAO-HNSF clinical practice guideline on BPPV recommends CRP, which typically results in prompt resolution of symptoms with a number needed to treat of 1-3. In addition, CRP has a relatively low risk for falls or transient provocation of BPPV symptoms.[1]

Two types of CRPs have demonstrated effectiveness in treating posterior canal BPPV: the Epley maneuver and the liberatory (Semont) maneuver. Both a 2014 Cochrane review of 11 randomized controlled trials[14] and a 2017 meta-analysis of 10 trials[15] found that the Epley and Semont maneuvers had similar effectiveness in rates of recovery and adverse effects.

To reduce cost and complications and promote a faster return to usual activities of daily living, the AAO-HNSF recommends against placing patients on postural restrictions, such as soft cervical collars, and suggests avoiding certain sleeping positions after CRP.[1] Systematic reviews have found little or no clinical benefit to postural restrictions after CRP.[16,17]

Observation, or watchful waiting, is a reasonable option for patients who may have contraindications to CRP or simply have a preference to do nothing immediately. BPPV has a reasonably high rate of spontaneous recovery; patients with the lateral canal variant recover more quickly than those with posterior canal BPPV.[18]

Vestibular rehabilitation comprises a broad spectrum of therapies, such as Brandt-Daroff and Cawthorne-Cooksey exercises, intended to allow patients to habituate and compensate for dizziness and balance dysfunction. A 2015 Cochrane review of 39 randomized controlled trials concluded that vestibular rehabilitation is a safe and effective treatment for unilateral peripheral vestibular dysfunction, but that CRP is more effective for BPPV in the short term.[19] The AAO-HNSF guideline states that vestibular rehabilitation may be better suited as an adjuvant therapy or as a treatment for patients who have persistent disability after CRP, refuse CRP, or have contraindications to CRP.[1]

Case 4: Avoiding Pitfalls in BPPV Treatment

A 64-year-old college professor underwent the Epley maneuver in an audiovestibular clinic after being diagnosed with BPPV. He had a bout of vertigo and emesis immediately after the procedure, but noted substantial improvement in symptoms afterward. However, he still felt somewhat unsteady on his feet as he stood up from the exam table. When offered the opportunity for a repeat CRP 1 week later, the patient was skeptical and asked whether he could try a medication instead.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: