Basis for recommendation

The information on advice to offer a person with benign paroxysmal positional vertigo (BPPV) is largely based on expert opinion in the American Academy of Otolaryngology — Head and Neck Surgery Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo [Bhattacharyya et al, 2017] and a number of review articles [Kim and Zee, 2014; Ludman, 2014; von Brevern, 2015; Wipperman, 2014; BMJ Best Practice, 2021].

 Prognosis, treatment, and avoiding recurrent episodes

• People with BPPV should be advised that their symptoms are likely to resolve with time but may recur, and that repositioning manoeuvres may be helpful. [Kim and Zee, 2014; Ludman, 2014; Bhattacharyya et al, 2017; BMJ Best Practice, 2021].
• CKS advises avoiding particular head positions as expert opinion suggests these can precipitate an episode of BPPV [Kim and Zee, 2014; Ludman, 2014; von Brevern, 2015; Wipperman, 2014; Bhattacharyya et al, 2017]. 

Safety issues

• Patients should be advised of the possible effect of BPPV on their safety [Bhattacharyya et al, 2017]. 
• Driving advice is derived from guidelines from the Driver and Vehicle Licensing Agency (DVLA) [DVLA, 2021], and expert opinion from previous reviewers of this CKS topic.
  • For detailed guidance on driving, see the DVLA's publication Assessing fitness to drive — a guide for medical professionals, available to download from www.gov.uk.
• The recommendations on safety in the workplace and the risk of falls at home are pragmatic, based on what CKS considers to be good clinical practice.

Epley manoeuvre

Be cautious performing the Epley manoeuvre if the person has neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, or morbid obesity. If in doubt about the safety of the procedure, seek specialist advice, or refer the person to a medically qualified balance specialist.

• Advise the person that they will experience transient vertigo during the manoeuvre.
• Stand at the side or behind the person to guide head movements. Maintain each head position for at least 30 seconds. If vertigo continues, wait until it has subsided.
  • Ideally, movements should be rapid, within 1 second, but this is often not possible, particularly in older people. Expert opinion suggests that the procedure can be effective if movements are carried out slowly.
• Start with the person sitting upright with their head turned 45 degrees to the affected side, then lie them back (with their head still turned 45 degrees) until the head is dependent 30 degrees over the edge of the couch (as if performing the Dix-Hallpike manoeuvre). Wait for at least 30 seconds. Then:
  • With the face upwards, but still tilted backwards by 30 degrees, rotate the head through 90 degrees to the opposite side.
  • Hold the head in this position for about 20 seconds and ask the person to roll onto the same side as they are facing.
  • Rotate the person's head so that they are facing obliquely downward with their nose 45 degrees below the horizontal.
  • Sit the person up sideways while the head remains rotated and tilted to the side.
  • Rotate the head to the central position and move the chin downwards by 45 degrees.
• There is usually no need to advise the person of any positional restrictions after the procedure has been performed. 
• A video of the Epley manoeuvre may help to illustrate the procedure.

Semont manoeuvre

Be cautious performing the Semont manoeuvre if the person has neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, or morbid obesity. If in doubt about the safety of the procedure, seek specialist advice, or refer the person to a medically qualified balance specialist.

• Ask the person to sit on a table or flat surface with their head turned away from the affected side.
• Lie the person on the side of the affected ear with the head slightly turned up. Observe nystagmus, if present, and wait in this position until at least 20 seconds after it stops. 
• Hold the person's head and neck with both hands and, moving back through the sitting position, move them over to the opposite side without turning the head during the position change so that they are in the opposite side-lying position with the head facing down. Remain in this position for at least 30 seconds.
• Slowly return the person to the sitting position.

Brandt-Daroff exercises

• If appropriate, instruct the person on how to perform these exercises at home. Advise them to:
  • Sit on the edge of a bed or couch with the eyes closed.
  • Quickly lie down sideways on one side with their eyes closed so that they are lying on their side with the lateral aspect of their occiput resting on the bed, with the head positioned as if they are looking towards the ceiling (rotated 45 degrees upwards).
  • Rest in this position for at least 30 seconds, until any vertigo subsides.
  • Keeping the eyes closed, sit upright again, and remain in this position for 30 seconds.
  • Repeat on the other side.
  • Repeat the sequence 3–4 times until they are symptom free.
  • Repeat 3–4 times a day until there have been 2 consecutive days without symptoms.

Basis for recommendation

The recommendations on management of people with benign paroxysmal positional vertigo (BPPV) are largely based on expert opinion in the American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical practice guideline: Benign paroxysmal positional vertigo [Bhattacharyya et al, 2017] and a number of review articles [Kim and Zee, 2014; Ludman, 2014; Wipperman, 2014; Dommaraju and Perera, 2016; Muncie et al, 2017; van Vugt, 2017; Turner, 2020; BMJ Best Practice, 2021].

Observation (watchful waiting)

• The recommendation that observation without treatment is an option is based on cohort and observational study data presented in the American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical practice guideline: Benign paroxysmal positional vertigo [Bhattacharyya et al, 2017] and is supported by expert opinion in review articles [Ludman, 2014; Wipperman, 2014].

Use of canalith/particle repositioning procedures

• The use of particle repositioning manoeuvres is widely recommended to treat BPPV [Kim and Zee, 2014; Wipperman, 2014; Dommaraju and Perera, 2016; Bhattacharyya et al, 2017; Muncie et al, 2017; van Vugt, 2017; Turner, 2020; BMJ Best Practice, 2021]. Serious adverse effects have not been reported, although temporary instability can persist for up to 24 hours post-procedure. However, most studies are carried out in secondary or tertiary care, which may limit their applicability to a primary care setting [Bhattacharyya et al, 2017]. 
• CKS has recommended caution when considering a canalith repositioning procedure for certain groups of people because expert opinion identified physical limitations which may contraindicate such procedures or require special examination conditions (including cervical problems, low back problems, ankylosing spondylitis, severe rheumatoid arthritis, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, and morbid obesity) [Bhattacharyya et al, 2017; BMJ Best Practice, 2021]. 

Epley manoeuvre

• The instructions on how to perform the Epley manoeuvre are based on expert opinion in articles and guidelines [Epley, 1992; Lempert et al, 1995; Kim and Zee, 2014; Bhattacharyya et al, 2017; Muncie et al, 2017], as well as information from previous expert reviewers of this CKS topic.
  • A trial showed symptom resolution in 77% of people with positional vertigo after one treatment with the Epley manoeuvre, and a further 20% when the treatment was repeated a week later [Epley, 1992]. 
  • There is evidence from a Cochrane systematic review (search date January 2014) that, when compared with sham manoeuvres or no treatment in the short term, the Epley manoeuvre is more effective at treating BPPV in terms of symptom resolution (n = 273; OR 4.42, 95% CI 2.62 to 7.44) and negative Dix-Hallpike test result (n = 507; OR 9.62, 95% CI 6.0 to 15.42) [Hilton and Pinder, 2014]. 
• Most evidence on canalith repositioning manoeuvres originates from specialist settings [Bhattacharyya et al, 2017]. A primary care study found a lower success rate with the Epley manoeuvre than studies in a specialist setting [Munoz et al, 2007], therefore further investigation into the effectiveness of canalith repositioning manoeuvres in primary care is ideally needed [Bhattacharyya et al, 2017]. 
• Postural restrictions following the Epley manoeuvre are not recommended, on the basis that without them, return to normal activities will be faster with less interruption to sleep and work [Bhattacharyya et al, 2017]. 
  • A Cochrane systematic review identified nine studies of postural restrictions following the Epley manoeuvre (for example use of a neck brace, head movement restrictions, sleeping upright). When compared with controls, there was a statistically significant difference between the groups, but this was found to translate to only a small additional benefit because of the effectiveness of the Epley manoeuvre alone. Minor complications (neck stiffness, horizontal BPPV, and dizziness) were reported [Hunt et al, 2012]. 
  • A meta-analysis of 11 studies with a collective total of 739 participants receiving a repositioning manoeuvre for BPPV, found no statistically significant difference in treatment efficacy between those undertaking post-manoeuvre postural restrictions (n = 362) and those not (n = 377) [Cromwell et al, 2018].

Semont manoeuvre

• The instructions on how to perform the Semont manoeuvre are based on an article explaining the procedure [Semont et al, 1988] and an American clinical practice guideline [Bhattacharyya et al, 2017]. The Semont manoeuvre may be more suitable for people who have difficulty with extending the neck [Kim and Zee, 2014].
  • A Cochrane systematic review concluded that outcomes for treatment with the Epley manoeuvre are similar to those with treatment with the Semont manoeuvre. The review identified two studies (n = 117) which, when data were pooled, suggested no difference between the two manoeuvres for resolution of nystagmus 7 days post-treatment (OR 0.78; 95% CI 0.32 to 1.88) [Hilton and Pinder, 2014].
  • Subsequent systematic reviews also showed better recovery and recurrence rates with the Semont manoeuvre than with no treatment, but similar effects when compared with the Epley manoeuvre [Liu et al, 2016; Zhang et al, 2017].
  • An additional small RCT (80 people with posterior BPPV: n = 40 Epley manoeuver and n = 40 Semont manoeuvre) found no statistically significant difference between the efficacy of these treatments as assessed by the Dix-Hallpike test (p = 0.251), but did find that the Epley manoeuvre was superior for the reduction of dizziness intensity (p = 0.009) [Sinsamutpadung and Kulthaveesup , 2021].
• The opinion of previous expert reviewers of this CKS topic was divided on the use of the Semont manoeuvre in primary care. The Epley manoeuvre was preferred, due to its more common use, and tolerability compared with the Semont manoeuvre. CKS has suggested the Semont manoeuvre as a possible alternative, as this is consistent with the opinion of some CKS expert reviewers and the evidence of similar efficacy for both the Epley and Semont manoeuvres (although this may not be directly applicable to a primary care setting). 

Brandt–Daroff exercises

• The instructions on how to perform Brandt–Daroff exercises are based on articles explaining the procedure [Brandt and Daroff, 1980; Hanley et al, 2001] and an American clinical practice guideline [Bhattacharyya et al, 2017]. 
• Evidence from an uncontrolled trial in 67 people found that 66 experienced relief from vertigo after performing the exercises for 3–14 days [Brandt and Daroff, 1980]. However, a Cochrane systematic review (search date January 2014) [Hilton and Pinder, 2014] found one study showing better outcomes 7 days after treatment with the Epley manoeuvre compared with regular Brandt-Daroff exercises. 
• Despite their comparative efficacy with the Epley manoeuvre, Brandt–Daroff exercises are unlikely to do harm and can be done at home, so they are recommended on the basis of expert opinion from previous reviewers of the CKS topic on Vertigo. It has also been noted that vestibular rehabilitation such as Brandt Daroff exercises may have a role in people who have persistent symptoms following repositioning manoeuvres; are unable to undergo repositioning manoeuvres because of physical comorbidities such as cervical or thoracic spine disease; or decline to undergo them [Bhattacharyya et al, 2017; Bressi et al, 2017; van Vugt, 2017]. 

Symptomatic drug treatment

• An American clinical practice guideline on the management of BPPV recommends, based on evidence in observational studies, that vestibular suppressant drugs are not a suitable routine treatment for BPPV or a substitute for repositioning manoeuvres. Those studies that showed improvement with medication were carried out over the same period that spontaneous resolution would be expected to occur [Bhattacharyya et al, 2017]. Expert opinion in review articles [Ludman, 2014; Wipperman, 2014; Muncie et al, 2017] was consistent with this, and suggests that most drugs are not effective in treating BPPV and may have adverse effects, such as drowsiness, increasing the risk of falls, effects on the results of diagnostic manoeuvres, and blunting central compensation.

Follow up

• This recommendation is based on observational study data and expert opinion in a US guideline suggesting that all people with BPPV should be followed up within 1 month. This allows reassessment of symptoms and gives an opportunity to offer further treatment if necessary [Bhattacharyya et al, 2017]. 

Basis for recommendation

Admission to hospital if severe nausea and vomiting

• This recommendation is largely pragmatic, based on what CKS considers to be good clinical practice. A review article relating to sudden-onset dizziness and vertigo also states that people who become dehydrated because of vomiting following accute attacks may require admission for intravenous fluids [Turner, 2020]. 

Referral if the expertise to perform a canalith repositioning procedure is not available in primary care

• Expert opinion within in the American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical practice guideline: Benign paroxysmal positional vertigo suggests that people with posterior canal BPPV should be referred to a clinician who can treat with a canalith repositioning procedure [Bhattacharyya et al, 2017].
• CKS considers it good clinical practice to refer the person to a medically-qualified balance specialist for treatment if the expertise to perform the Epley manoeuvre is not available in primary care.

Referral if physical limitations affect the safety or practicality of carrying out canalith repositioning procedures in primary care

• This recommendation is extrapolated from expert opinion in the American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical practice guideline: Benign paroxysmal positional vertigo. It states that these procedures may not be appropriate for people with certain medical conditions and that specialized equipment (such as examination tables) may be required [Bhattacharyya et al, 2017].

Referral if a canalith repositioning procedure has been performed and repeated in primary care and symptoms are still present

• The consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society Benign paroxysmal positional vertigo: diagnostic criteria suggests that repeated lack of response to positional therapeutic manoeuvres requires consideration of other diagnoses [von Brevern, 2015] and expert opinion in review articles advises referral if symptoms do not resolve [Parnes et al, 2003; Cranfield et al, 2010].
• The opinion of previous expert reviewers of this CKS topic suggests that if the Epley manoeuvre has been tried twice, with no resolution of symptoms, the person should be referred to exclude an alternative diagnosis.

Referral for atypical symptoms and signs

• CKS has based this recommendation on expert opinion in review articles which states that BPPV can sometimes occur in the horizontal or anterior canal, both ears, or multiple canals and in these cases it can be difficult to identify patterns of nystagmus and treat appropriately, therefore referral to a specialist is recommended [Kim and Zee, 2014; BMJ Best Practice, 2021]. 
• Atypical symptoms or signs (for example hearing loss, tinnitus, signs of middle ear infection, other associated neurological symptoms and signs) may be indicative of a differential diagnosis [BMJ Best Practice, 2021]. For more information on other conditions causing vertigo, see the CKS topic on Vertigo.

Referral if symptoms do not resolve in 4 weeks

• This recommendation is based on expert opinion in the American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical practice guideline: Benign paroxysmal positional vertigo which recommends referral to a clinician who can evaluate people with persistent symptoms to determine if they have unresolved BPPV, or another underlying peripheral vestibular or central disorder. The aim of this strategy is to reduce the risk of missed diagnoses and provide appropriate treatment [Bhattacharyya et al, 2017]. This approach is also supported by expert opinion in a review article on the diagnosis and treatment of BPPV in primary care [Cranfield et al, 2010]. 

Secondary care treatments

• Expert opinion in the American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical practice guideline: Benign paroxysmal positional vertigo is that vestibular rehabilitation (a series of physical therapy exercises to improve central compensation for vertigo caused by a peripheral deficit [Wipperman, 2014]) is an option, but is not usually used first-line for uncomplicated BPPV [Bhattacharyya et al, 2017]. Brandt-Daroff and Cawthorne-Cooksey are commonly encountered vestibular rehabilitation exercises [Bhattacharyya et al, 2017; Bressi et al, 2017]. 
  • A Cochrane systematic review found that, for unilateral peripheral dysfunction, vestibular rehabilitation is more effective than sham interventions or control in terms of resolving dizziness and improving day-to-day function. The Cochrane authors also noted that, specifically for people with BPPV, physical repositioning manoeuvres are more effective at achieving complete symptom resolution in the short term. In the longer term there was evidence to suggest that combining physical repositioning manoeuvres with vestibular rehabilitation improved functional recovery [McDonnell and Hillier, 2015]. 
  • A review of the literature reiterated the hierarchy of interventions to treat BPPV, starting with a repositioning manoeuvre [Bressi et al, 2017]. It has also been noted that vestibular rehabilitation may have a role in people who have persistent disability following repositioning manoeuvres, are unable to undergo repositioning manoeuvres because of physical comorbidities such as cervical or thoracic spine disease, or decline to undergo them [Bhattacharyya et al, 2017; Bressi et al, 2017; van Vugt, 2017]. 
• Apart from therapeutic manoeuvres, other treatments that may occasionally be used as a last resort for people with severe, refractory symptoms of BPPV include surgical procedures such as transection of the posterior ampullary nerve or occlusion of the posterior semicircular canal [Kim and Zee, 2014; Ludman, 2014; Wipperman, 2014; BMJ Best Practice, 2021].