Benign Paroxysmal Positional Vertigo - Treatment

Treatment

Two treatments have been found effective for relieving symptoms of posterior canal BPPV: the canalith repositioning procedure (CRP) or Epley maneuver, and the liberatory or Semont maneuver. The CRP employs gravity to move the calcium build-up that causes the condition. The particle repositioning maneuver can be performed during a clinic visit by health professionals or taught to patients to practice at home. In the Semont maneuver, patients themselves are able to achieve canalith repositioning. Both treatments, when performed by a health professional, appear to be equally effective. When practiced at home, the CRP is more effective than the Semont maneuver. The most effective repositioning treatment for posterior canal BPPV is the therapist-performed CRP combined with home practiced CRP.

The Epley maneuver (particle repositioning) does not address the actual presence of the particles (otoconia), rather it changes their location. The maneuver aims to move these particles from some locations in the inner ear which cause symptoms such as vertigo, and reposition them to where they do not cause these problems.

The Brandt-Daroff exercises may be prescribed by the clinician as a home treatment method usually in conjunction with particle repositioning maneuvers or in lieu of the particle repositioning maneuver. The exercise is a form of habituation exercise, designed to allow the patient to become accustomed to the position which causes the vertigo symptoms. The Brandt-Daroff exercises are performed in a similar fashion to the Semont maneuver; however, as the patient rolls onto the unaffected side, the head is rotated toward the affected side. The exercise is typically performed 3 times a day with 5-10 repetitions each time, until symptoms of vertigo have resolved for at least 2 days.

For the Lateral (Horizontal) canal, a separate maneuver has been used for productive results. It is unusual for the lateral canal to respond to the canalith repositioning procedure used for the posterior canal BPPV. Treatment is therefore geared towards moving the canalith from the lateral canal into the vestibule. The roll maneuver or its variations are used and involves rolling the patient 360 degrees in a series of steps to reposition the particles. This maneuver is generally performed by a trained clinician who begins seated at the head of the examination table with the patient supine There are four stages, each a minute apart and at the third position the horizontal canal is oriented in a vertical position with the patient's neck flexed and on forearm and elbows. When all four stages are completed, the head roll test is repeated and if negative treatment ceases.

Medical treatment with anti-vertigo medications may be considered in acute, severe exacerbation of BPPV, but in most cases are not indicated. These primarily include drugs of the anti-histamine and anti-cholinergic class, such as meclizine and scopolamine respectively. The medical management of vestibular syndromes has become increasingly popular over the last decade, and numerous novel drug therapies (including existing drugs with new indications), have emerged for the treatment of vertigo/dizziness syndromes. These drugs vary considerably in their mechanisms of action, with many of them being receptor or ion channel-specific. Among them, include betahistine or dexamethasone/gentamicin for the treatment of Ménière's disease, carbamazepine/oxcarbazepine for the treatment of paroxysmal dysarthria and ataxia in multiple sclerosis, metoprolol/topiramate or valproic acid/tricyclic antidepressant for the treatment of vestibular migraine, and 4-aminopyridine for the treatment of episodic ataxia type 2 and downbeat and upbeat nystagmus. These drug therapies offer symptomatic treatment, and do not affect the disease process or resolution rate. Medications may be used to suppress symptoms during the positioning maneuvers if the patient's symptoms are severe and intolerable. More dose-specific studies are required however, in order to determine the most effective drug(s) for both acute symptom relief and long term remission of the condition. For a complete list of these novel therapies and their associated target symptoms, follow the link below to the Informahealthcare website.

Surgical treatments, such as a semi-circular canal occlusion, do exist for BPPV but carry the same risk as any neurosurgical procedure. Surgery is reserved as a last resort option for severe and persistent cases which fail vestibular rehabilitation (including particle repositioning and habituation therapy).

Devices such as a head over heels "rotational chair" are available at some tertiary care centers Home devices, like the DizzyFIX, are also available for the treatment of BPPV and vertigo.

The Semont maneuver has a cure rate of 90.3%. It is performed as follows:

1. The patient is seated on a treatment table with their legs hanging off the side of the table. The therapist then turns the patient’s head towards the unaffected side 45 degrees.
2. The therapist then quickly tilts the patient so they are lying on the affected side. The head position is maintained, so their head is turned up 45 degrees. This position is maintained for 3 minutes. The purpose is to allow the debris to move to the apex of the ear canal.
3. The patient is then quickly moved so they are lying on the unaffected side with their head in the same position (now facing downwards 45 degrees). This position is also held for 3 minutes. The purpose of this position is to allow the debris to move toward the exit of the ear canal.
4. Finally, the patient is slowly brought back to an upright seated position. The debris should then fall into the utricle of the canal and their symptoms of vertigo should decrease or end completely. Some patients will only need one treatment, but others may need multiple treatments depending on the severity of their BPPV.