SPECIAL ARTICLE

Practice Parameter: Therapies for benign

paroxysmal positional vertigo
(an evidence-based review)
Report of the Quality Standards Subcommittee of the American
Academy of Neurology

T.D. Fife, MD INTRODUCTION Benign paroxysmal positional aligned with gravity. This produces a paroxysm
D.J. Iverson, MD vertigo (BPPV) is a clinical syndrome character- of vertigo and nystagmus after a brief latency. Po-
T. Lempert, MD ized by brief recurrent episodes of vertigo trig- sitioning the head in the opposite direction re-
J.M. Furman, MD, gered by changes in head position with respect to verses the direction of the nystagmus. These
PhD gravity. BPPV is the most common cause of recur- responses often fatigue upon repeat positioning.
R.W. Baloh, MD rent vertigo, with a lifetime prevalence of 2.4%.1 The duration, frequency, and intensity of symptoms
R.J. Tusa, MD, PhD The term BPPV excludes vertigo caused by le- of BPPV vary, and spontaneous recovery occurs fre-
T.C. Hain, MD sions of the CNS. BPPV results from abnormal quently. Table e-1 outlines the characteristics of
S. Herdman, PT, PhD, stimulation of the cupula within any of the three BPPV by canal type.
FAPTA semicircular canals (figure e-1 on the Neurology® Repositioning maneuvers are believed to treat
M.J. Morrow, MD Web site at www.neurology.org); most cases of BPPV by moving the canaliths from the semicir-
G.S. Gronseth, MD BPPV affect the posterior canal. The cupular exci- cular canal to the vestibule from which they are
tatory response is usually related to movement of absorbed. There are a number of repositioning
otoliths (calcium carbonate crystals) that create a maneuvers in use, but they lack standardization.
Address correspondence and
reprint requests to the
current of endolymph within the affected semicir- The figures and Web-based video clips do not in-
American Academy of cular canal. The most common form of BPPV oc- clude all variations but represent those maneuvers
Neurology, 1080 Montreal curs when otoliths from the macula of the utricle fall and treatments used in the Class I and Class II
Ave., St. Paul, MN 55116
guidelines@aan.com into the lumen of the posterior semicircular canal studies that are reviewed as well as several others
responding to the effect of gravity. These ectopic in common use.
otoliths, which have been observed intraoperatively, This practice parameter seeks to answer the fol-
are referred to as canaliths. The canaliths are dense lowing questions: 1) What maneuvers effectively
and move in the semicircular canal when the head treat posterior canal BPPV? 2) Which maneuvers are
position is changed with respect to gravity; the cana- effective for anterior and horizontal canal BPPV? 3)
lith movement ultimately deflects the cupula, lead- Are postmaneuver restrictions necessary? 4) Is con-
ing to a burst of vertigo and nystagmus. In some current mastoid vibration important for efficacy of
cases, canaliths adhere to the cupula, causing cupu- the maneuvers? 5) What is the efficacy of habitua-
lolithiasis, which is a form of BPPV less responsive tion exercises, Brandt–Daroff exercises, or patient
to treatment maneuvers. self-administered treatment maneuvers? 6) Are med-
Typical signs of BPPV are evoked when the ications effective for BPPV? 7) Is surgical occlusion
head is positioned so that the plane of the affected of the posterior canal or singular neurectomy effec-
semicircular canal is spatially vertical and thus tive for BPPV?

GLOSSARY
AAN ⫽ American Academy of Neurology; BPPV ⫽ benign paroxysmal positional vertigo; CONSORT ⫽ Consolidated Stan-
Supplemental data at dards of Reporting Trials; CRP ⫽ canalith repositioning procedure; NNT ⫽ number needed to treat.
www.neurology.org
From the Barrow Neurological Institute and University of Arizona College of Medicine (T.D.F.), Phoenix, AZ; Humboldt Neurological
Medical Group, Inc. (D.J.I.), Eureka, CA; Department of Neurology (T.L.), Schlosspark-Klinik, Berlin, Germany; Department of
Otolaryngology (J.M.F.), University of Pittsburgh, PA; Department of Neurology (R.W.B.), Reed Neurological Research Center, University
of California, Los Angeles, CA; Departments of Neurology (R.J.T.) and Rehabilitation Medicine (S.H.), Emory University; Atlanta, GA;
Northwestern University (T.C.H.), Chicago, IL; Providence Multiple Sclerosis Center (M.J.M.), Portland, OR; and University of Kansas
(G.S.G.), Kansas City, KS.
Approved by the Quality Standards Subcommittee on May 1, 2007; by the Practice Committee on June 21, 2007; and by the American
Academy of Neurology Board of Directors in July 2007.
QSS Subcommittee members, AAN classification of evidence, Classification of recommendations, Conflict of Interest Statement, Mission
Statement of the QSS, and references e1– e32 are available as supplemental data on the Neurology® Web site at www.neurology.org.
Disclosure: Author disclosures are provided at the end of the article.
All figures in this manuscript and online were printed with permission from Barrow Neurological Institute.

Copyright © 2008 by AAN Enterprises, Inc. 2067

 The first Class I study of 36 patients2 com-
Figure 1 Dix–Hallpike maneuver for diagnosis of
right posterior canal benign
pared the canalith repositioning procedure (CRP)
paroxysmal positional vertigo (figure 2) with a sham maneuver where the pa-
(BPPV) tient was placed in a supine position with the af-
fected ear down for 5 minutes and then sat up. All
patients were symptomatic for at least 2 months;
the median duration of symptoms was 17 months
(range 2–240 months) in the treatment group and
4 months (range 2–276 months) in the control
group, a difference that approached significance.
At 4 weeks, 61% of the treated group reported
complete symptom resolution, vs 20% of the
sham-treated group (p ⫽ 0.032). The number
The patient’s head is turned 45 degrees toward the side to
needed to treat (NNT) was 2.44. The NNT is an
be tested and then laid back quickly. If BPPV is present, nys-
tagmus ensues usually within seconds. epidemiologic measure that indicates the number
of patients that had to have treatment to elimi-
DESCRIPTION OF THE ANALYTIC PROCESS nate symptoms in one patient. The Dix–Hallpike
Otoneurologists with expertise in BPPV and gen- maneuver was negative in 88.9% of treated pa-
eral neurologists with methodologic expertise tients vs 26.7% in sham-treated patients (p ⬍
were invited by the Quality Standards Subcom- 0.001; NNT ⫽ 1.60), as measured by an observer
mittee (appendix e-1) to perform this review. Us- blinded to treatment.
ing the four-tiered classification scheme described The second Class I randomized controlled trial
in appendix e-2, author panelists rated all rele- and crossover study,3 of 66 patients with a diag-
vant articles between 1966 and June 2006. nosis of posterior BPPV based on a positive Dix–
Articles included in this analysis met all of these Hallpike maneuver, compared a CRP (figure 2)
criteria: 1) BPPV was diagnosed by both symptoms with a sham procedure. The sham procedure con-
of positional vertigo lasting less than 60 seconds, sisted of a CRP performed on the contralateral,
and paroxysmal positional nystagmus in response asymptomatic ear.
to the Dix–Hallpike maneuver (figure 1) or other After 24 hours, 80% of treated patients were
appropriate provocative maneuver; 2) for all forms asymptomatic and had no nystagmus with the
of BPPV, the nystagmus was characterized by a brief
Dix–Hallpike maneuver compared with 10% of
latency before the onset of nystagmus or a reduction
sham patients (p ⬍ 0.001; NNT ⫽ 1.43). At this
of nystagmus with repeat Dix–Hallpike maneuvers
point, all patients in both the treatment and con-
(fatigability); 3) for posterior canal BPPV, a positive
trol groups with a persistently positive Dix–
Dix–Hallpike maneuver was defined by the pres-
Hallpike maneuver underwent a CRP. Ninety-
ence of upbeating and torsional nystagmus with the
three percent of patients from the original control
top pole of rotation beating toward the affected
group reported resolution of symptoms 24 hours
(downside) ear; and 4) for horizontal canal BPPV,
after undergoing the CRP. By 1 week, 94% of pa-
the Dix–Hallpike or supine roll maneuver produced
tients in the original treatment group and 82% of
horizontal geotropic (toward the ground) or apo-
patients in the original control group (all of whom
geotropic (away from the ground) direction-
underwent a CRP at 24 hours) were asymptomatic
changing paroxysmal positional nystagmus.
(p value not stated). At 4 weeks, 85% of patients in
Geotropic direction-changing positional nystag-
both groups were asymptomatic.
mus refers to paroxysmal right beating nystagmus
Three studies were rated as Class II because
when the supine head is turned to the right and
the method of allocation concealment was not
paroxysmal left beating nystagmus with the su-
specified. Allocation concealment is a technique
pine head turned to the left. Conversely, apogeo-
for preventing researchers from inadvertently in-
tropic indicates the nystagmus is right beating
fluencing which patients are assigned to the treat-
with the head turned to the left and left beating
ment or placebo group; inadequate allocation
with head turned to the right.
concealment may cause selection bias that overes-
ANALYSIS OF EVIDENCE Question 1: What timates the treatment effect.7
maneuvers effectively treat posterior canal BPPV? The first Class II study of 50 patients4 com-
Canalith repositioning procedure for BPPV. Of 15 ran- pared a CRP with the same sham maneuver per-
domized controlled trials identified, there were formed by Lynn et al.,2 with blinded outcome
two Class I studies2,3 and three Class II studies.4-6 measurements of symptom resolution and absent

2068 Neurology 70 May 27, 2008 (Part 1 of 2)

 ined at weekly intervals by a blinded observer.
Figure 2 Canalith repositioning procedure for right-sided benign paroxysmal
positional vertigo
Patients with a positive Dix–Hallpike maneu-
ver who were assigned to the treatment group
underwent repeat CRP. A questionnaire was
administered to patients with a negative Dix–
Hallpike maneuver.
At 1 week, 41% of treated patients were symp-
tom free, vs 3% of untreated controls (p ⫽ 0.005;
NNT ⫽ 2.63). The Dix–Hallpike maneuver was
negative in 75.9% of treated patients vs 48.2% of
untreated controls, an absolute difference of
27.7% (95% CI 0.241– 0.489, p ⫽ 0.03; NNT ⫽
3.68). At 2 weeks, 65% were symptom free in the
treatment group vs 3% of controls (p ⬍ 0.005). At
3 weeks, 65% were symptom free vs 21% of the
controls (p ⫽ 0.014). There were no significant
differences at 4 weeks. The control group used
cinnarizine more often (23 doses) than did the
treatment group (5.8 doses, p ⫽ 0.001).
The third study6 randomized 124 patients to a
CRP, a Semont liberatory maneuver (figure 3),
Brandt–Daroff exercises (figure e-2), habituation
exercises, or a sham maneuver of slow neck rota-
tion and flexion performed with the patient in a
sitting position. The diagnosis for posterior canal
BPPV was based on history and paroxysmal posi-
tional nystagmus in response to the Dix–Hallpike
maneuver (figure 1). The median duration of
Steps 1 and 2 are identical to the Dix–Hallpike maneuver. The patient is held in the right head symptoms was 4 months (range 10 days to 30
hanging position (Step 2) for 20 to 30 seconds, and then in Step 3 the head is turned 90 years). The outcome measure was an arbitrary
degrees toward the unaffected side. Step 3 is held for 20 to 30 seconds before turning the
patient-rated vertigo intensity and frequency scale
head another 90 degrees (Step 4) so the head is nearly in the face-down position. Step 4 is
held for 20 to 30 seconds, and then the patient is brought to the sitting up position. The of 1 to 10 (10 being the most severe or frequent),
movement of the otolith material within the labyrinth is depicted with each step, showing how recorded by a blinded observer.
otoliths are moved from the semicircular canal to the vestibule. Although it is advisable for
The treatment effect in this study is difficult to
the examiner to guide the patient through these steps, it is the patient’s head position that is
the key to a successful treatment.
quantify because the results are expressed in the
form of regression curves, rather than as discrete
nystagmus in response to the Dix–Hallpike ma- values. At 90 days after treatment, vertigo fre-
neuver. One to 2 weeks after treatment, 50% quency was reportedly “significantly reduced” in
of the treated group reported symptom resolution both CRP– and Semont maneuver–treated pa-
vs 19% in the sham group, an absolute difference tients. Both treatment maneuvers were superior
of 31% (95% CI 0.06-0.56, p ⫽ 0.02; NNT ⫽ to the sham maneuver (CRP, p ⫽ 0.021; Semont
3.22). Using the absence of nystagmus after the maneuver, p ⫽ 0.010) for vertigo intensity. The
Dix–Hallpike maneuver as an outcome measure- vertigo scores were not significantly different be-
ment, an improvement was seen in 65% of tween the CRP and Semont maneuver. There was
treated patients vs 38% of sham patients, a significantly less frequent vertigo in those treated
27% absolute difference (95% CI 0.02– 0.52, by either CRP or Semont maneuver compared
p ⫽ 0.046; NNT ⫽ 3.7). with Brandt–Daroff exercises (p ⫽ 0.033).
Another Class II study5 randomized 29 pa- The remaining randomized controlled trials
tients to a CRP and another 29 patients to no were graded as Class IV because they did not
treatment. The diagnosis of posterior BPPV was clearly state whether the outcomes were obtained
based on observing nystagmus after the Dix– in a blinded and independent manner8-15 or be-
Hallpike maneuver and a “complete neurotologi- cause of important baseline differences between
cal examination.” All patients were given a study and control groups.16
prescription for cinnarizine to use for vertigo. The literature search also yielded four meta-
Over the next month, all patients were exam- analyses and one systematic review. All four

Neurology 70 May 27, 2008 (Part 1 of 2) 2069

 77% of those treated with Semont maneuver (p ⫽
Figure 3 Semont maneuver for right-sided benign paroxysmal positional vertigo
0.027); 62% of patients treated with Brandt–
Daroff exercises were asymptomatic at 3 months.
Conclusion. Two Class I studies and three Class
II studies have demonstrated a short-term (1 day
to 4 weeks) resolution of symptoms in patients
treated with the CRP, with NNT ranging from
1.43 to 3.7. The Semont maneuver is possibly
more effective than no treatment (Class III), a
sham treatment (Class II), or Brandt–Daroff exer-
cises (Class IV) as treatment for posterior canal
BPPV. Two Class IV studies comparing CRP with
Semont maneuver have produced conflicting re-
sults; one showed no difference between groups,
and the other showed a lower recurrence rate in
patients undergoing CRP.
While sitting up in Step 1, the patient’s head is turned 45 degrees toward the left side, and
then the patient is rapidly moved to the side-lying position as depicted in Step 2. This position
Recommendation (appendix e-3). Canalith reposi-
is held for 30 seconds or so, and then the patient is rapidly taken to the opposite side-lying tioning procedure is established as an effective
position without pausing in the sitting position or changing the head position relative to the and safe therapy that should be offered to patients
shoulder. This is in contrast to the Brandt–Daroff exercises that entail pausing in the sitting
of all ages with posterior semicircular canal BPPV
position and turning the head with body position changes.
(Level A recommendation). The Semont maneu-
ver is possibly effective for BPPV but receives only
meta-analyses17-20 concluded that CRP and Se-
a Level C recommendation based on a single
mont maneuver have significantly greater efficacy
Class II study. Although many experts believe
than no treatment in BPPV. All references in-
cluded in these four meta-analyses were reviewed that the Semont maneuver is as effective as cana-
individually for this practice parameter. lith repositioning maneuver, based on currently
In all these studies, complications of nausea published articles the Semont maneuver can only
and vomiting, fainting, or conversion to horizon- be classified as “possibly effective.” There is in-
tal canal BPPV occurred in 12% of patients. In a sufficient evidence to establish the relative effi-
retrospective study of 85 patients treated with a cacy of the Semont maneuver to CRP (Level U).
CRP,21 6% developed a conversion to either hori- Question 2: Which maneuvers are the most effective
zontal canal BPPV or anterior canal BPPV. treatments for horizontal canal and anterior canal
Semont maneuver for BPPV. One Class II study6 BPPV? Horizontal canal BPPV. Horizontal canal
showed that patients treated with Semont maneu- BPPV accounts for 10% to 17% of BPPV,25-29
ver were “significantly” improved compared with though some reports have been even higher.30,31
those treated with a sham maneuver. A Class III The nystagmus of horizontal canal BPPV is hori-
study22 randomized 156 patients to Semont ma- zontal and changes direction when the head is
neuver, medical therapy (flunarizine 10 mg/day turned to the right or left while supine (direction-
for 60 days), or no treatment. At 6-month follow- changing paroxysmal positional nystagmus). The
up, 94.2% of patients treated with Semont ma- direction-changing positional nystagmus may be
neuver reported symptom resolution, vs 57.7% of either geotropic or apogeotropic.31 The geotropic
patients treated with flunarizine and 34.6% of pa- form, which is thought to result from free-moving
tients who received no treatment. otoconial debris in the long arm of the semicircular
A Class IV study23 comparing Semont maneu- duct, is generally more responsive to treatment. The
ver and a CRP either with or without post- apogeotropic form is likely due to otoconial mate-
treatment instructions found success rates for all rial in the short arm of the canal or attached to the
groups ranging from 88% to 96%, with no differ- cupula (cupulolithiasis).24,32 Hence, one seeks to
ences between groups. Another Class IV study24 convert the more treatment-resistant apogeotropic
compared patients randomized to treatment with to the more treatment-responsive geotropic nystag-
CRP, Semont maneuver, or Brandt–Daroff exer- mus form of horizontal canal BPPV.32,33
cises. Symptom resolution among those treated The nystagmus and vertigo of horizontal canal
with either CRP or Semont maneuver at 1 week BPPV may be provoked by the Dix–Hallpike ma-
was the same (74% vs 71%; 24% for Brandt– neuver but are more reliably induced by the su-
Daroff exercises). At 3-month follow-up, 93% of pine head roll test or so-called Pagnini–McClure
patients treated with CRP were asymptomatic vs maneuver (figure 4).34-36 The methods used to de-

2070 Neurology 70 May 27, 2008 (Part 1 of 2)

 the most widely published treatments for hori-
Figure 4 Supine roll test (Pagnini–McClure maneuver) to detect horizontal canal
benign paroxysmal positional vertigo (BPPV)
zontal canal BPPV.25,26,29,31,32,34,36,38,e1,e2 Success in
treatment, based on all Class IV studies, is proba-
bly ⬍75%32,e2 but ranges from approximately
50% to nearly 100%. However, the studies used
differing and sometimes unclear endpoints, and
many lacked control groups to allow comparison
between the treatment and the natural rate of res-
olution of this condition.
The Gufoni maneuver is another technique
that has been reported as effective in treating hor-
izontal canal BPPVe3 (figure e-3, A and B). Several
studies, all Class IV, have reported success using
this or a similar maneuver for horizontal canal
BPPV for both the geotropic and apogeotropic
nystagmus forms.32,33,38,e4 Similarly, the Vannuc-
chi–Asprella liberatory maneuver may be effec-
tive, but there is only limited Class IV data
The patient may be taken from sitting to straight supine position (1). The head is turned to the
supporting its use.38,e5,e6 Casani et al.32 and Appiani
right side (2) with observation of nystagmus and then turned back to face up (1). Then the
head is turned to the left side (3). The side with the most prominent nystagmus is taken to be et al.33 review other techniques used with success in
the affected horizontal semicircular canal. The direction of nystagmus in each position deter- the treatment of both the geotropic and apogeotro-
mines whether the horizontal canal BPPV is of the geotropic or apogeotropic type. pic forms of horizontal canal BPPV.
Another treatment reported as effective30,32,36,e2,e7
termine the affected side in horizontal canal BPPV
is referred to as forced prolonged positioning. With
are described elsewhere.30,37,38,e1 CRP or modified
this method, the patient lies down laterally to the
Epley maneuvers are usually ineffective for hori-
affected side, and the head is then turned 45 degrees
zontal canal BPPV,21,34 so a number of alternative
toward the ground and maintained in that position
maneuvers have been devised.
for 12 hours before the patient is returned to the
Variations of the roll maneuver (Lempert ma-
starting position. Some authors advocate this tech-
neuver or barbecue roll maneuver) (figure 5) are
nique for refractory horizontal canal BPPV.32,e3 Us-
ing this approach, one Class IV study reported
Figure 5 Lempert roll maneuver for right-sided horizontal canal benign remission rates of 75% to 90%.32
paroxysmal positional vertigo (BPPV) Anterior canal BPPV. Anterior canal BPPV is usu-
ally transitory and most often is the result of “ca-
nal switch” that occurs in the course of treating
other more common forms of BPPV.21
We identified only two studies specifically ad-
dressing the treatment of anterior canal BPPV;
both were Class IV studies.e8,e9 Success rates were
between 92% and 97%, though there were no
controls to determine whether this represents an
improvement over the natural history of this fre-
quently self-resolving form of BPPV.
Conclusion. Based on Class IV studies, variations
of the Lempert supine roll maneuver, the Gufoni
method, or forced prolonged positioning seem mod-
erately effective for horizontal canal BPPV. Two un-
controlled Class IV studies report high response
rates to maneuvers for anterior canal BPPV.
Recommendation: None (Level U).

Question 3: Are postmaneuver activity restrictions

When it is determined to be horizontal canal BPPV affecting the right side, the patient is taken necessary after canalith repositioning procedure? In
through a series of step-wise 90-degree turns away from the affected side in Steps 1
one Class I study2 and one Class II4 study demon-
through 5, holding each position for 10 to 30 seconds. From Step 5, the patient positions his
or her body to the back (6) in preparation for the rapid and simultaneous movement from the strating the benefit of CRP, patients wore a cervi-
supine face up to the sitting position (7). cal collar for 48 hours and avoided sleeping on the

Neurology 70 May 27, 2008 (Part 1 of 2) 2071

 affected side for 1 week. One Class I study3 and maneuver,” Brandt–Daroff exercises, “habituation
two Class II studies5,6 that demonstrated the ben- exercises,” or a sham treatment found that patients
efit of CRP used no post-treatment restrictions or treated with habituation exercises did no better than
instructions. These studies were not designed to those treated with a sham procedure.6 Patients
determine whether such restrictions affect treat- treated with Brandt–Daroff exercises did worse
ment success; however, there seems to be little dif- than those treated with CRP or liberatory maneu-
ference in the rate of treatment success whether or vers but were not compared with sham-treated
not restrictions were included.
patients.
Six Class IV studies comparing CRP with and
A Class IV study24 compared Brandt–Daroff
without post-treatment activity restriction were
exercises, performed three times daily, with the
identified.23,e10-e14 Five studies23,e10-e13 showed no
Semont maneuver or CRP. Patients treated with
added benefit from post-treatment activity re-
striction or positions. Only one study showed a maneuvers were pretreated with diazepam and
minimal benefit in patients with post-activity re- given postmaneuver activity restrictions; patients
strictions, as measured by the number of maneu- treated with Brandt–Daroff exercises were not.
vers required to produce a negative Dix–Hallpike Compliance with the exercises was not recorded.
maneuver.e14 At 1-week follow-up, 24% of patients treated
Conclusion and recommendation. Five Class IV with Brandt–Daroff exercises were symptom free,
studies support the omission of post-treatment vs 74% of those treated with the Semont maneu-
activity restrictions; one study supports the use of ver or CRP. Given the limitations of the study, its
post-treatment restrictions. There is insufficient validity is questionable.
evidence to determine the efficacy of post- Three Class IV studies investigated the effi-
maneuver restrictions in patients treated with cacy of patient-administered treatment for
CRP (Level U). BPPV using various techniques. One study
Question 4: Is it necessary to include mastoid vibration found 88% improvement of BPPV when treated
with repositioning maneuvers? Mastoid vibration with CRP and home CRP compared with 69%
was included in the original Epley repositioning improvement in those only treated with CRP
maneuver. One Class II study,e15 comparing pa- once.e19 Another study reported improved reso-
tients with posterior canal BPPV treated by “ap- lution of nystagmus among patients that self-
propriate canalith repositioning maneuvers,” administered CRP (64% recovery) vs self-
performed with and without vibration, showed administered Brandt–Daroff exercises (23%).e20
no difference in immediate symptom resolution The third study found that 95% had resolution
or relapse rate between groups.
of positional nystagmus 1 week after self-
A Class III studye16 compared patients treated
treatment with CRP vs 58% of self-treatment
by CRP with and without mastoid vibration.
with a modified Semont maneuver.e21
There was no difference in symptom relief be-
Conclusion and recommendation. One Class II and
tween the groups at 4 to 6 weeks (p ⫽ 0.68).
one Class IV study suggest that Brandt–Daroff
Two Class IV studiese17,e18 showed no differ-
exercises or habituation exercises are less effective
ence in the rate of symptom resolution between
than CRP in the treatment of posterior canal
patients treated by a CRP with or without mas-
toid vibration. A third Class IV study9 reported BPPV. Self-administered Brandt–Daroff exercises
that of patients treated by a CRP with vibration, or habituation exercises are less effective than
92% were “improved,” vs 60% improvement CRP in the treatment of posterior canal BPPV
with CRP alone. (Level C). There is insufficient evidence to recom-
Conclusion and recommendation. One Class II, one mend or refute self-treatment using Semont ma-
Class III, and two Class IV studies showed no neuver or CRP for BPPV (Level U).
added benefit when mastoid vibration was added Question 6: What is the efficacy of medication treat-
to a CRP as treatment for posterior canal BPPV. ments for BPPV? One Class III studye22 found no
Mastoid oscillation is probably of no added bene- difference between lorazepam, 1 mg three times
fit to patients treated with CRP for posterior ca- daily; diazepam, 5 mg three times daily; or pla-
nal BPPV (Level C recommendation). cebo over the 4-week study period. Another Class
Question 5: What is the efficacy of Brandt–Daroff III study21 found that flunarizine was more effec-
exercises, habituation exercises, or patient self- tive than no treatment but less effective than Se-
administered treatments for BPPV? A Class II study mont maneuver in eliminating symptoms. There
that randomized patients to a CRP, a “liberatory are no randomized controlled trials of meclizine

2072 Neurology 70 May 27, 2008 (Part 1 of 2)

or other drugs used for motion sickness in the mates that 6% of his time is spent on canalith repositioning
treatment of BPPV. procedures. Dr. Iverson has nothing to disclose. Dr. Lempert
Conclusion and recommendation. A single Class III estimates that ⬍5% of his time is spent on videooculogra-
phy. Dr. Furman holds stock options in Neurokinetics, has
study did not demonstrate that lorazepam or di-
received research support from Merck, has served as an ex-
azepam hastened resolution of symptoms in
pert witness on vestibular function, and estimates that 1% of
BPPV. A single Class III study demonstrated some his time is spent on the Epley maneuver. Dr. Baloh estimates
benefit of flunarizine, a drug that is unavailable in 5% of his time is spent on ENG. Dr. Tusa estimates that 5%
the United States, in BPPV. There is no evidence of his time is spent on quantified positional testing. Dr. Hain
to support a recommendation of any medication estimates that 5% of his time is spent on ENG and 5% on
in the routine treatment for BPPV (Level U). VEMP. Dr. Herdman received research support from
VAMC and served as an expert witness on the Hallpike-Dix
Question 7: What are the safety and efficacy of sur-
maneuver. Dr. Morrow has received honoraria from Bio-
gical treatments for posterior canal BPPV? All stud- genIdec and has served as an expert witness and consultant
ies of surgical treatment for refractory BPPV are on medico-legal proceedings. Dr. Gronseth has received
Class IV. The most common procedure is fenes- speaker honoraria from Pfizer, GlaxoSmithKline, and
tration and occlusion of the posterior semicircu- Boehringer Ingelheim and served on the IDMC Committee
lar canal. Five studies, e23-e27 with a total of 86 of Ortho-McNeil.
patients undergoing canal occlusion, reported
“complete relief” of BPPV symptoms in 85, as as- DISCLAIMER
certained by the treating surgeon. Reported com- This statement is provided as an educational service of the
plications included a “mild” conductive hearing American Academy of Neurology. It is based on an assess-
loss for 4 weeks or less, “mild” and “transient” ment of current scientific and clinical information. It is
unsteadiness in most patients, and a high fre- not intended to include all possible proper methods of
quency sensorineural hearing loss in 6 patients. care for a particular neurologic problem or all legitimate
In a Class IV study of singular neurectomy criteria for choosing to use a specific procedure. Neither is
it intended to exclude any reasonable alternative method-
as a treatment for intractable BPPV,e28 96.8%
ologies. The American Academy of Neurology recognizes
were reported to have “complete relief”; severe
that specific patient care decisions are the prerogative of
sensorineural hearing loss occurred in 3.7% of
the patient and the physician caring for the patient, based
patients. on all of the circumstances involved.
Conclusion and recommendation. Six unblinded,
retrospective Class IV studies report relief from Received August 1, 2007. Accepted in final form February
symptoms of BPPV in nearly every patient under- 23, 2008.
going posterior semicircular canal occlusion or
singular neurectomy. Because the studies are
REFERENCES
Class IV, they do not provide sufficient evidence
1. von Brevern M, Radtke A, Lezius F, et al. Epidemiol-
to recommend or refute posterior semicircular ca- ogy of benign paroxysmal positional vertigo: a popula-
nal occlusion or singular neurectomy as treatment tion based study. J Neurol Neurosurg Psychiatr 2007;
for BPPV (Level U). 78:710–715.
2. Lynn S, Pool A, Rose D, Brey R, Suman V. Random-
RECOMMENDATIONS FOR FUTURE RE- ized trial of the canalith repositioning procedure. Oto-
SEARCH Class I studies are needed to clarify the laryngol Head Neck Surg 1995;113:712–720.
best treatments for horizontal canal BPPV. Future 3. von Brevern M, Seelig T, Radtke A, Tiel-Wilck K,
studies on these topics should adhere to the Neuhauser H. Long-term efficacy of Epley’s manoeu-
Consolidated Standards of Reporting Trials vre: a double-blind randomized trial. J Neurol Neuro-
(CONSORT) criteria using validated, clinically surg Psychiatr 2006;77:980–982.
4. Froehling DA, Bowen JM, Mohr DN, et al. The cana-
relevant outcomes.
lith repositioning procedure for the treatment of be-
nign paroxysmal positional vertigo: a randomized
PROGNOSIS AND RECURRENCE RATE The re-
controlled trial. Mayo Clin Proc 2000;75:695–700.
lapse rate and second recurrence rate of BPPV are 5. Yimtae K, Srirompotong S, Srirompotong S, Sae-Seaw
not fully established. Short-term relapse rates range P. A randomized trial of the canalith repositioning pro-
from 7% to nearly 23% within a year of treatment, cedure. Laryngoscope 2003;113:828–832.
but long-term recurrences may approach 50%, de- 6. Cohen HS, Kimball KT. Effectiveness of treatments for
pending on the age of the patient. e29-e32 benign paroxysmal positional vertigo of the posterior
canal. Otol Neurotol 2005;26:1034–1040.
DISCLOSURE 7. Schulz KF, Grimes DA. Allocation concealment in ran-
The authors report the following disclosures: Dr. Fife has domised trials: defending against deciphering. Lancet
received research support from GlaxoSmithKline and esti- 2002;359:614–618.

Neurology 70 May 27, 2008 (Part 1 of 2) 2073

 8. Sherman D, Massoud EA. Treatment outcomes of be- 24. Soto Varela A, Bartual Magro J, Santos Perez S, et al.
nign paroxysmal positional vertigo. J Otolaryngol Benign paroxysmal vertigo: a comparative prospective
2001;30:295–299. study of the efficacy of Brandt and Daroff exercises,
9. Li JC. Mastoid oscillation: a critical factor for success Semont and Epley maneuver. Rev Laryngol Otol Rhi-
in canalith repositioning procedure. Otolaryngol Head nol (Bord) 2001;122:179–183.
Neck Surg 1995;112:670–675. 25. White JA, Coale KD, Catalano PJ, Oas JG. Diagnosis
10. Blakley BW. A randomized, controlled assessment of and management of horizontal semicircular canal be-
the canalith repositioning maneuver. Otolaryngol nign paroxysmal positional vertigo. Otolaryngol Head
Head Neck Surg 1994;110:391–396. Neck Surg 2005;133:278–284.
11. Lempert T, Wolsley C, Davies R, et al. Three hundred 26. Prokopakis EP, Chimona T, Tsagournisakis M, et
sixty-degree rotation of the posterior semicircular ca-
al. Benign paroxysmal positional vertigo: 10-year ex-
nal for treatment of benign positional vertigo: a
perience in treating 592 patients with canalith repo-
placebo-controlled trial. Neurology 1997;49:729–733.
sitioning procedure. Laryngoscope 2005;115:1667–
12. Wolf M, Hertanu T, Novikov I, Kronenberg J. Epley’s
1671.
manoeuvre for benign paroxysmal positional vertigo: a
27. Caruso G, Nuti D. Epidemiological data from 2270
prospective study. Clin Otolaryngol 1999;24:43–46.
PPV patients. Audiological Med 2005;3:7–11.
13. Asawavichianginda S, Isipradit P, Snidvongs K, et al.
28. Leopardi G, Chiarella G, Serafini G, et al. Paroxysmal
Canalith repositioning for benign paroxysmal posi-
tional vertigo: a randomized, controlled trial. Ear Nose positional vertigo: short- and long-term clinical and
Throat J 2000;79:732–734. methodological analyses of 794 patients. Acta Otolar-
14. Angeli SI, Hawley R, Gomez O. Systematic approach yngol Ital 2003;23:155–160.
to benign paroxysmal positional vertigo in the elderly. 29. Fife TD. Recognition and management of horizontal
Otolaryngol Head Neck Surg 2003;128:719–725. canal benign positional vertigo. Am J Otol 1998;19:
15. Sridhar S, Panda N. Particle repositioning manoeuvre 345–351.
in benign paroxysmal positional vertigo: is it really 30. Koo JW, Moon IJ, Shim WS, Moon SY, Kim JS. Value
safe? J Otolaryngol 2005;34:41–45. of lying-down nystagmus in the lateralization of hori-
16. Chang AK, Schoeman G, Hill M. A randomized clini- zontal semicircular canal benign paroxysmal positional
cal trial to assess the efficacy of the Epley maneuver in vertigo. Otol Neurol 2006;27:367–371.
the treatment of acute benign positional vertigo. Acad 31. Nuti D, Agus G, Barbieri M-T, Passali D. The manage-
Emerg Med 2004;11:918–924. ment of horizontal-canal paroxysmal positional ver-
17. Lopez-Escamaez J, Gonzalez-Sanchez M, Salinero J. tigo. Acta Otolaryngol 1998;118:455–460.
Meta-analysis of the treatment of benign paroxysmal 32. Casani AP, Vannucchi G, Fattori B, Berrettini S. The
positional vertigo by Epley and Semont maneuvers. treatment of horizontal canal positional vertigo: our
Acta Otorrinolaringol Esp 1999;50:366–370. experience in 66 cases. Laryngoscope 2002;112:172–
18. Woodworth BA, Gillespie MB, Lambert PR. The canalith 178.
repositioning procedure for benign positional vertigo: a 33. Appiani GC, Catania G, Gagliardi M, Cuiuli G. Repo-
meta-analysis. Laryngoscope 2004;114:1143–1146. sitioning maneuver for the treatment of the apogeotro-
19. Teixeira LJ, Machado JN. Maneuvers for the treat-
pic variant of horizontal canal benign paroxysmal
ment of benign positional paroxysmal vertigo: a sys-
positional vertigo. Otol Neurotol 2005;26:257–260.
tematic review. Rev Bras Otorrinolaringol (Engl Ed)
34. Lempert T, Tiel-Wilck K. A positional maneuver for
2006;72:130–139.
treatment of horizontal-canal benign positional ver-
20. Hilton M, Pinder D. The Epley manoeuvre for benign
tigo. Laryngoscope 1996;106:476–478.
paroxysmal positional vertigo: a systematic review.
35. McClure JA. Horizontal canal BPV. J Otolaryngol
Clin Otolaryngol Allied Sci 2002;27:440–445.
1985;14:30–35.
21. Herdman SJ, Tusa RJ. Complications of the canalith
repositioning procedure. Arch Otolaryngol Head Neck 36. Appiani GC, Gagliardi M, Magliulo G. Physical treat-
Surg 1996;122:281–286. ment of horizontal canal benign positional vertigo. Eur
22. Salvinelli F, Casale M, Trivelli M, et al. Benign parox- Arch Otorhinolaryngol 1997;254:326–328.
ysmal positional vertigo: a comparative prospective 37. Han BI, Oh HJ, Kim JS. Nystagmus while recumbent
study on the efficacy of Semont’s maneuver and no in horizontal canal benign paroxysmal positional ver-
treatment strategy. Clin Ter 2003;154:7–11. tigo. Neurology 2006;66:706–710.
23. Massoud EA, Ireland DJ. Post-treatment instructions 38. Asprella Libonati G. Diagnostic and treatment strategy
in the nonsurgical management of benign paroxysmal of the lateral semicircular canal canalolithiasis. Acta
positional vertigo. J Otolaryngol 1996;25:121–125. Otorhinolaryngol Ital 2005;25:277–283.

2074 Neurology 70 May 27, 2008 (Part 1 of 2)