Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

initial presentation

1st line – patient education and reassurance

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ACUTE
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initial presentation
1st line – 

patient education and reassurance

The initial step in managing BPPV is patient education and reassurance.[35][42][43]​ This is done by explaining its non-life-threatening nature and favourable prognosis, with spontaneous remission in one third of patients at 3 weeks and the majority of patients at 6 months from onset.​[7][43][68]

Patients should be made aware that BPPV is a highly treatable condition, with the majority of episodes resolving after the administration of a single particle repositioning manoeuvre (PRM).[2][44][45] However, relapses and remissions can occur unpredictably in both treated and untreated patients.[48] Patients who have secondary BPPV (e.g., secondary to vestibular neuronitis) should be encouraged to return to normal physical activity to facilitate central nervous system compensation.[43]

Plus – 3-position particle repositioning manoeuvre (PRM)

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ACUTE
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initial presentation
|
repositioning manoeuvres not contra-indicated
Plus – 

3-position particle repositioning manoeuvre (PRM)

Treatment recommended for ALL patients in selected patient group

Contra-indications to repositioning manoeuvres include severe cervical disease, unstable cardiovascular disease, suspected vertebrobasilar disease, and high-grade carotid stenosis.[48] For those patients without contra-indications, the literature describes many minor variations of the PRM technique, but the 3-position PRM variant of the Epley manoeuvre is recommended.[54][91] The PRM has a well-documented short-term efficacy, with the majority of patients treated successfully after a single PRM attempt.[2][44][45] Post-manoeuvre instructions, including post-PRM postural restrictions, are not necessary.[59][60][61][62]

The procedure involves the following steps: [Figure caption and citation for the preceding image starts]: Particle-repositioning manoeuvre (right ear)Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693; used with permission [Citation ends].com.bmj.content.model.Caption@7d73f459

Place the patient in a sitting position at the end of the examination table.

Rotate the head 45° towards the affected ear, then swiftly place the patient in a supine position with the head hanging 30° below the horizontal at the end of the examining table (Dix-Hallpike position).

Observe for primary stage nystagmus.

Maintain this position for 1-2 minutes.

The head is rotated 90° towards the opposite ear while maintaining the head hanging position.

Continue then to roll the whole patient another 90° towards the unaffected side until their head is facing 180° from the original Dix-Hallpike position. This change in position should take <3-5 seconds.

Observe for secondary-stage nystagmus. A favourable response occurs when the secondary-stage nystagmus is in the same direction as the primary-stage nystagmus, because the canalith particles would still be moving towards the utricle; an unfavourable response occurs when the nystagmus is in the opposite direction, which results when the particles regress away from the utricle towards its original position. Absence of nystagmus is not uncommon and may indicate mixed results, such as partial (incomplete) BPPV resolution.

Maintain the final position for 30-60 seconds, and then have the patient sit up. Upon sitting, there should be no vertigo or nystagmus in a successful manoeuvre, because the particles will have been cleared from the posterior semicircular canal back into the utricle.

For horizontal canal and anterior canal BPPV, special manoeuvres exist, but these patients should be referred to a specialist centre.

Consider – vestibular suppressant medication (only useful in small subset of patients)

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ACUTE
|
initial presentation
|
repositioning manoeuvres not contra-indicated
Consider – 

vestibular suppressant medication (only useful in small subset of patients)

Additional treatment recommended for SOME patients in selected patient group

Medication is not an effective treatment for BPPV. The use of vestibular suppressant medications such as the benzodiazepines (lorazepam, diazepam) and antihistamines (meclozine, dimenhydrinate, promethazine) is not recommended in the vast majority of BPPV cases.[35][48][49][50]

Vestibular suppressant medications are not curative and are often ineffective at symptom management given the sudden and short-lived onset of BPPV.[43][48]

Suppressants also produce unwanted adverse effects such as drowsiness. The central nervous system (CNS) suppression that these drugs cause may result in disease prolongation by inhibiting central compensation for a co-existing vestibular loss: for example, in cases of BPPV secondary to vestibular neuronitis.[43][48]

There is, however, a small subpopulation of patients with prolonged autonomic dysfunction and imbalance who may benefit from vestibular suppressant medication (e.g., lorazepam or diazepam), but the CNS depressant adverse effects of these medications must be carefully weighed prior to initiating treatment.[43][48]

Rarely, a small subset of patients become extremely nauseated and emetic during a repositioning manoeuvre, necessitating stopping the manoeuvre. Such individuals may benefit from a prophylactic antiemetic (e.g., meclozine, dimenhydrinate, promethazine) prior to subsequent manoeuvres.[48]

Primary options

lorazepam: 0.5 to 2 mg intravenously/intramuscularly every 4-8 hours when required; or 0.5 to 2 mg intravenously/intramuscularly as a single dose prior to repositioning manoeuvre

OR

diazepam: 2-10 mg orally/intravenously every 4-8 hours when required; or 2-10 mg orally/intravenously as single dose prior to repositioning manoeuvre

OR

meclozine: 12.5 to 25 mg orally every 4-8 hours when required, maximum 100 mg/day; or 12.5 to 25 mg orally as a single dose approximately 60 minutes prior to repositioning manoeuvre

OR

dimenhydrinate: 25-50 mg orally every 4-6 hours when required, maximum 400 mg/day; or 25-50 mg orally as a single dose approximately 30 minutes prior to repositioning manoeuvre

OR

promethazine: 12.5 to 25 mg orally/intravenously every 4-6 hours when required, maximum 100 mg/day; or 12.5 to 25 mg orally/intravenously as a single dose approximately 30-60 minutes prior to repositioning manoeuvre

Consider – vestibular rehabilitation exercises

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ACUTE
|
initial presentation
|
repositioning manoeuvres not contra-indicated
Consider – 

vestibular rehabilitation exercises

Additional treatment recommended for SOME patients in selected patient group

Some patients may benefit from vestibular rehabilitation exercises to promote functional recovery and prevent recurrence, particularly if they are at higher risk of falls or have residual generalised dizziness after BPPV treatment.[35][70]​ Vestibular rehabilitation consists of home exercises or a customised programme delivered by a therapist. Suitable home exercises include the modified self-Epley, modified Semont, and half somersault manoeuvres.[71][72][73][74]

Plus – Semont repositioning manoeuvre

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ACUTE
|
initial presentation
|
repositioning manoeuvres not contra-indicated and failed 3-position PRM
Plus – 

Semont repositioning manoeuvre

Treatment recommended for ALL patients in selected patient group

Although the PRM and Semont manoeuvre share a similar mechanism and efficacy, the PRM is used preferentially by most clinicians in North America because it is more comfortable for the patient and simpler to perform, especially in overweight and older patients.[42][55][56][57][58][7] If the PRM fails after repeated sessions, then the Semont (liberatory) manoeuvre is the next treatment option. The procedure involves the following steps: [Figure caption and citation for the preceding image starts]: Liberatory manoeuvre of Semont (right ear)Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693; used with permission [Citation ends].com.bmj.content.model.Caption@4eb5a962

Sit the patient midway along the long side of an examination table, with their legs hanging over the edge.

Rotate the head 45° towards the unaffected side. While maintaining the head rotation, swiftly place the patient's upper body in a side-lying position on the affected side, with the head resting on the examination table and now facing upwards. This may induce nystagmus and vertigo because of particle movement towards the apex of the semicircular canal. Maintain this position until the vertigo and nystagmus stop (1-2 minutes).

Move the patient rapidly through the sitting position of step 1 and into the opposite side-lying position while maintaining the same head rotation, so that the head is resting on the examination table and now facing downwards. A nystagmus response in the same direction would indicate that the particles are exiting the semicircular canal. The transition from step 2 to 3 relies on inertia, and therefore it must be done very quickly. Maintain this position until the vertigo and nystagmus stop (1-2 minutes). Slowly return the patient to the sitting position of step 1.

Consider – vestibular suppressant medication (only useful in small subset of patients)

Back
ACUTE
|
initial presentation
|
repositioning manoeuvres not contra-indicated and failed 3-position PRM
Consider – 

vestibular suppressant medication (only useful in small subset of patients)

Additional treatment recommended for SOME patients in selected patient group

Medication is not an effective treatment for BPPV. The use of vestibular suppressant medications such as the benzodiazepines (lorazepam, diazepam) and antihistamines (meclozine, dimenhydrinate, promethazine) is not recommended in the vast majority of BPPV cases.[35][48][49][50]

Vestibular suppressant medications are not curative and are often ineffective at symptom management given the sudden and short-lived onset of BPPV.[43][48]

Suppressants also produce unwanted adverse effects such as drowsiness. The central nervous system (CNS) suppression that these drugs cause may result in disease prolongation by inhibiting central compensation for a co-existing vestibular loss: for example, in cases of BPPV secondary to vestibular neuronitis.[43][48]

There is, however, a small subpopulation of patients with prolonged autonomic dysfunction and imbalance who may benefit from vestibular suppressant medication, but the CNS depressant adverse effects of these medications must be carefully weighed prior to initiating treatment.[43][48]

Rarely, a small subset of patients become extremely nauseated and emetic during a repositioning manoeuvre, necessitating stopping the manoeuvre. Such individuals may benefit from an antiemetic vestibular suppressant (e.g., meclozine, promethazine) prior to subsequent manoeuvres.[48]

Primary options

lorazepam: 0.5 to 2 mg intravenously/intramuscularly every 4-8 hours when required; or 0.5 to 2 mg intravenously/intramuscularly as a single dose prior to repositioning manoeuvre

OR

diazepam: 2-10 mg orally/intravenously every 4-8 hours when required; or 2-10 mg orally/intravenously as single dose prior to repositioning manoeuvre

OR

meclozine: 12.5 to 25 mg orally every 4-8 hours when required, maximum 100 mg/day; or 12.5 to 25 mg orally as a single dose approximately 60 minutes prior to repositioning manoeuvre

OR

dimenhydrinate: 25-50 mg orally every 4-6 hours when required, maximum 400 mg/day; or 25-50 mg orally as a single dose approximately 30 minutes prior to repositioning manoeuvre

OR

promethazine: 12.5 to 25 mg orally/intravenously every 4-6 hours when required, maximum 100 mg/day; or 12.5 to 25 mg orally/intravenously as a single dose approximately 30-60 minutes prior to repositioning manoeuvre

Consider – vestibular rehabilitation exercises

Back
ACUTE
|
initial presentation
|
repositioning manoeuvres not contra-indicated and failed 3-position PRM
Consider – 

vestibular rehabilitation exercises

Additional treatment recommended for SOME patients in selected patient group

Some patients may benefit from vestibular rehabilitation exercises to promote functional recovery and prevent recurrence, particularly if they are at higher risk of falls or have residual generalised dizziness after BPPV treatment.[35][70]​ Vestibular rehabilitation consists of home exercises or a customised programme delivered by a therapist. Suitable home exercises include the modified self-Epley, modified Semont, and half somersault manoeuvres.[71][72][73][74]

Plus – modified and specialised treatments

Back
ACUTE
|
initial presentation
|
repositioning manoeuvres and vestibular rehabilitation exercises ineffective, contra-indicated or not tolerated
Plus – 

modified and specialised treatments

Treatment recommended for ALL patients in selected patient group

If repositioning manoeuvres fail after repeat surgery visits, then prompt referral to a tertiary specialist dizziness clinic is indicated.[7]

Patients with contra-indications to repositioning manoeuvres and those unable to tolerate repositioning manoeuvres or exercises may benefit from vestibular habituation therapy under the supervision of a physiotherapist.[43]

For patients with cervical spine or other issues that limit neck extension, a 30° bed tilt during the PRM can avoid the need for neck extension. It should be noted that a 30° tilt is sufficient to cause the patient to slide down the bed. Thus, although most PRMs can be easily carried out by a solo clinician, a PRM with a 30° bed tilt will require at least one assistant.

A chair that can spin and position the patient in any plane in space without the need for neck movements is available.[75]

ONGOING

multiple repositioning manoeuvres and vestibular rehabilitation exercises ineffective

1st line – surgery

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ONGOING
|
multiple repositioning manoeuvres and vestibular rehabilitation exercises ineffective
1st line – 

surgery

The vast majority of BPPV cases will respond to the repositioning manoeuvres or resolve spontaneously. The surgical treatment of BPPV is reserved for unrelenting, incapacitating cases where repeated attempts with repositioning manoeuvres and vestibular rehabilitation exercises have failed.[78][79] Surgical treatment may also be considered for patients who respond to PRMs but have unremitting recurrences soon afterwards, to the extent that they are keen on a definitive solution rather than repeated PRMs. Less than 1% of BPPV patients will ever require surgery, but because BPPV is so common, that number of surgical candidates is not negligible.[80]

Prior to surgery, all other diagnoses must be excluded and imaging of the posterior fossa is a prerequisite. There are two surgical procedures for BPPV: singular neurectomy and posterior canal occlusion. Posterior canal occlusion surgery is the recommended procedure and has been shown to be a highly efficacious, safe, and reproducible technique in numerous studies.[78][80][82][83][84][85][86][87] The technique is based on the premise that obstruction of the posterior semicircular canal lumen prevents endolymphatic flow and thus renders the cupula immobile.[79][81]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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