10 neurology-2008-fife-2067-74

DOI 10121201wnl000031337877444ac2008702067-2074 Neurology

T D Fife D J Iverson T Lempert et al Standards Subcommittee of the American Academy of Neurology

vertigo (an evidence-based review) Report of the Quality Practice Parameter Therapies for benign paroxysmal positional

This information is current as of May 27 2008

httpwwwneurologyorgcontent70222067fullhtmllocated on the World Wide Web at

The online version of this article along with updated information and services is

0028-3878 Online ISSN 1526-632Xsince 1951 it is now a weekly with 48 issues per year Copyright All rights reserved Print ISSN

reg is the official journal of the American Academy of Neurology Published continuouslyNeurology

Practice Parameter Therapies for benignparoxysmal positional vertigo(an evidence-based review)Report of the Quality Standards Subcommittee of the AmericanAcademy of Neurology

TD Fife MDDJ Iverson MDT Lempert MDJM Furman MDPhD

RW Baloh MDRJ Tusa MD PhDTC Hain MDS Herdman PT PhDFAPTA

MJ Morrow MDGS Gronseth MD

INTRODUCTION Benign paroxysmal positionalvertigo (BPPV) is a clinical syndrome character-ized by brief recurrent episodes of vertigo trig-gered by changes in head position with respect togravity BPPV is the most common cause of recur-rent vertigo with a lifetime prevalence of 241

The term BPPV excludes vertigo caused by le-sions of the CNS BPPV results from abnormalstimulation of the cupula within any of the threesemicircular canals (figure e-1 on theNeurologyreg

Web site at wwwneurologyorg) most cases ofBPPV affect the posterior canal The cupular exci-tatory response is usually related to movement ofotoliths (calcium carbonate crystals) that create acurrent of endolymph within the affected semicir-cular canal The most common form of BPPV oc-curswhen otoliths from themacula of the utricle fallinto the lumen of the posterior semicircular canalresponding to the effect of gravity These ectopicotoliths which have been observed intraoperativelyare referred to as canaliths The canaliths are denseand move in the semicircular canal when the headposition is changedwith respect to gravity the cana-lith movement ultimately deflects the cupula lead-ing to a burst of vertigo and nystagmus In somecases canaliths adhere to the cupula causing cupu-lolithiasis which is a form of BPPV less responsiveto treatment maneuvers

Typical signs of BPPV are evoked when thehead is positioned so that the plane of the affectedsemicircular canal is spatially vertical and thus

aligned with gravity This produces a paroxysmof vertigo and nystagmus after a brief latency Po-sitioning the head in the opposite direction re-verses the direction of the nystagmus Theseresponses often fatigue upon repeat positioningThe duration frequency and intensity of symptomsof BPPV vary and spontaneous recovery occurs fre-quently Table e-1 outlines the characteristics ofBPPV by canal type

Repositioning maneuvers are believed to treatBPPV by moving the canaliths from the semicir-cular canal to the vestibule from which they areabsorbed There are a number of repositioningmaneuvers in use but they lack standardizationThe figures and Web-based video clips do not in-clude all variations but represent those maneuversand treatments used in the Class I and Class IIstudies that are reviewed as well as several othersin common use

This practice parameter seeks to answer the fol-lowing questions 1) What maneuvers effectivelytreat posterior canal BPPV 2)Whichmaneuvers areeffective for anterior and horizontal canal BPPV 3)Are postmaneuver restrictions necessary 4) Is con-current mastoid vibration important for efficacy ofthe maneuvers 5) What is the efficacy of habitua-tion exercises BrandtndashDaroff exercises or patientself-administered treatmentmaneuvers 6) Aremed-ications effective for BPPV 7) Is surgical occlusionof the posterior canal or singular neurectomy effec-tive for BPPV

Supplemental data atwwwneurologyorg

Address correspondence andreprint requests to theAmerican Academy ofNeurology 1080 MontrealAve St Paul MN 55116guidelinesaancom

GLOSSARYAAN American Academy of Neurology BPPV benign paroxysmal positional vertigo CONSORT Consolidated Stan-dards of Reporting Trials CRP canalith repositioning procedure NNT number needed to treat

From the Barrow Neurological Institute and University of Arizona College of Medicine (TDF) Phoenix AZ Humboldt NeurologicalMedical Group Inc (DJI) Eureka CA Department of Neurology (TL) Schlosspark-Klinik Berlin Germany Department ofOtolaryngology (JMF) University of Pittsburgh PA Department of Neurology (RWB) Reed Neurological Research Center Universityof California Los Angeles CA Departments of Neurology (RJT) and Rehabilitation Medicine (SH) Emory University Atlanta GANorthwestern University (TCH) Chicago IL Providence Multiple Sclerosis Center (MJM) Portland OR and University of Kansas(GSG) Kansas City KS

Approved by the Quality Standards Subcommittee on May 1 2007 by the Practice Committee on June 21 2007 and by the AmericanAcademy of Neurology Board of Directors in July 2007

QSS Subcommittee members AAN classification of evidence Classification of recommendations Conflict of Interest Statement MissionStatement of the QSS and references e1ndashe32 are available as supplemental data on theNeurologyreg Web site at wwwneurologyorg

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

SPECIAL ARTICLE

Copyright copy 2008 by AAN Enterprises Inc 2067

DESCRIPTION OF THE ANALYTIC PROCESSOtoneurologists with expertise in BPPV and gen-eral neurologists with methodologic expertisewere invited by the Quality Standards Subcom-mittee (appendix e-1) to perform this review Us-ing the four-tiered classification scheme describedin appendix e-2 author panelists rated all rele-vant articles between 1966 and June 2006

Articles included in this analysis met all of thesecriteria 1) BPPV was diagnosed by both symptomsof positional vertigo lasting less than 60 secondsand paroxysmal positional nystagmus in responseto the DixndashHallpike maneuver (figure 1) or otherappropriate provocative maneuver 2) for all formsof BPPV the nystagmuswas characterized by a brieflatency before the onset of nystagmus or a reductionof nystagmus with repeat DixndashHallpike maneuvers(fatigability) 3) for posterior canal BPPV a positiveDixndashHallpike maneuver was defined by the pres-ence of upbeating and torsional nystagmus with thetop pole of rotation beating toward the affected(downside) ear and 4) for horizontal canal BPPVthe DixndashHallpike or supine roll maneuver producedhorizontal geotropic (toward the ground) or apo-geotropic (away from the ground) direction-changing paroxysmal positional nystagmusGeotropic direction-changing positional nystag-mus refers to paroxysmal right beating nystagmuswhen the supine head is turned to the right andparoxysmal left beating nystagmus with the su-pine head turned to the left Conversely apogeo-tropic indicates the nystagmus is right beatingwith the head turned to the left and left beatingwith head turned to the right

ANALYSIS OF EVIDENCE Question 1 Whatmaneuvers effectively treat posterior canal BPPVCanalith repositioning procedure for BPPVOf15 ran-domized controlled trials identified there weretwo Class I studies23 and three Class II studies4-6

The first Class I study of 36 patients2 com-pared the canalith repositioning procedure (CRP)(figure 2) with a sham maneuver where the pa-tient was placed in a supine position with the af-fected ear down for 5 minutes and then sat up Allpatients were symptomatic for at least 2 monthsthe median duration of symptoms was 17 months(range 2ndash240 months) in the treatment group and4 months (range 2ndash276 months) in the controlgroup a difference that approached significance

At 4 weeks 61 of the treated group reportedcomplete symptom resolution vs 20 of thesham-treated group (p 0032) The numberneeded to treat (NNT) was 244 The NNT is anepidemiologic measure that indicates the numberof patients that had to have treatment to elimi-nate symptoms in one patient The DixndashHallpikemaneuver was negative in 889 of treated pa-tients vs 267 in sham-treated patients (p

0001 NNT 160) as measured by an observerblinded to treatment

The second Class I randomized controlled trialand crossover study3 of 66 patients with a diag-nosis of posterior BPPV based on a positive DixndashHallpike maneuver compared a CRP (figure 2)with a sham procedure The sham procedure con-sisted of a CRP performed on the contralateralasymptomatic ear

After 24 hours 80 of treated patients wereasymptomatic and had no nystagmus with theDixndashHallpike maneuver compared with 10 ofsham patients (p 0001 NNT 143) At thispoint all patients in both the treatment and con-trol groups with a persistently positive DixndashHallpike maneuver underwent a CRP Ninety-three percent of patients from the original controlgroup reported resolution of symptoms 24 hoursafter undergoing the CRP By 1 week 94 of pa-tients in the original treatment group and 82 ofpatients in the original control group (all of whomunderwent a CRP at 24 hours) were asymptomatic(p value not stated) At 4 weeks 85 of patients inboth groups were asymptomatic

Three studies were rated as Class II becausethe method of allocation concealment was notspecified Allocation concealment is a techniquefor preventing researchers from inadvertently in-fluencing which patients are assigned to the treat-ment or placebo group inadequate allocationconcealment may cause selection bias that overes-timates the treatment effect7

The first Class II study of 50 patients4 com-pared a CRP with the same sham maneuver per-formed by Lynn et al2 with blinded outcomemeasurements of symptom resolution and absent

Figure 1 DixndashHallpike maneuver for diagnosis ofright posterior canal benignparoxysmal positional vertigo(BPPV)

The patientrsquos head is turned 45 degrees toward the side tobe tested and then laid back quickly If BPPV is present nys-tagmus ensues usually within seconds

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

nystagmus in response to the DixndashHallpike ma-neuver One to 2 weeks after treatment 50of the treated group reported symptom resolutionvs 19 in the sham group an absolute differenceof 31 (95 CI 006-056 p 002 NNT 322) Using the absence of nystagmus after theDixndashHallpike maneuver as an outcome measure-ment an improvement was seen in 65 oftreated patients vs 38 of sham patients a27 absolute difference (95 CI 002ndash 052p 0046 NNT 37)

Another Class II study5 randomized 29 pa-tients to a CRP and another 29 patients to notreatment The diagnosis of posterior BPPV wasbased on observing nystagmus after the DixndashHallpike maneuver and a ldquocomplete neurotologi-cal examinationrdquo All patients were given aprescription for cinnarizine to use for vertigoOver the next month all patients were exam-

ined at weekly intervals by a blinded observerPatients with a positive DixndashHallpike maneu-ver who were assigned to the treatment groupunderwent repeat CRP A questionnaire wasadministered to patients with a negative DixndashHallpike maneuver

At 1 week 41 of treated patients were symp-tom free vs 3 of untreated controls (p 0005NNT 263) The DixndashHallpike maneuver wasnegative in 759 of treated patients vs 482 ofuntreated controls an absolute difference of277 (95 CI 0241ndash0489 p 003 NNT

368) At 2 weeks 65 were symptom free in thetreatment group vs 3 of controls (p 0005) At3 weeks 65 were symptom free vs 21 of thecontrols (p 0014) There were no significantdifferences at 4 weeks The control group usedcinnarizine more often (23 doses) than did thetreatment group (58 doses p 0001)

The third study6 randomized 124 patients to aCRP a Semont liberatory maneuver (figure 3)BrandtndashDaroff exercises (figure e-2) habituationexercises or a sham maneuver of slow neck rota-tion and flexion performed with the patient in asitting position The diagnosis for posterior canalBPPV was based on history and paroxysmal posi-tional nystagmus in response to the DixndashHallpikemaneuver (figure 1) The median duration ofsymptoms was 4 months (range 10 days to 30years) The outcome measure was an arbitrarypatient-rated vertigo intensity and frequency scaleof 1 to 10 (10 being the most severe or frequent)recorded by a blinded observer

The treatment effect in this study is difficult toquantify because the results are expressed in theform of regression curves rather than as discretevalues At 90 days after treatment vertigo fre-quency was reportedly ldquosignificantly reducedrdquo inboth CRPndash and Semont maneuverndashtreated pa-tients Both treatment maneuvers were superiorto the sham maneuver (CRP p 0021 Semontmaneuver p 0010) for vertigo intensity Thevertigo scores were not significantly different be-tween the CRP and Semont maneuver There wassignificantly less frequent vertigo in those treatedby either CRP or Semont maneuver comparedwith BrandtndashDaroff exercises (p 0033)

The remaining randomized controlled trialswere graded as Class IV because they did notclearly state whether the outcomes were obtainedin a blinded and independent manner8-15 or be-cause of important baseline differences betweenstudy and control groups16

The literature search also yielded four meta-analyses and one systematic review All four

Figure 2 Canalith repositioning procedure for right-sided benign paroxysmalpositional vertigo

Steps 1 and 2 are identical to the DixndashHallpike maneuver The patient is held in the right headhanging position (Step 2) for 20 to 30 seconds and then in Step 3 the head is turned 90degrees toward the unaffected side Step 3 is held for 20 to 30 seconds before turning thehead another 90 degrees (Step 4) so the head is nearly in the face-down position Step 4 isheld for 20 to 30 seconds and then the patient is brought to the sitting up position Themovement of the otolith material within the labyrinth is depicted with each step showing howotoliths are moved from the semicircular canal to the vestibule Although it is advisable forthe examiner to guide the patient through these steps it is the patientrsquos head position that isthe key to a successful treatment

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

meta-analyses17-20 concluded that CRP and Se-mont maneuver have significantly greater efficacythan no treatment in BPPV All references in-cluded in these four meta-analyses were reviewedindividually for this practice parameter

In all these studies complications of nauseaand vomiting fainting or conversion to horizon-tal canal BPPV occurred in 12 of patients In aretrospective study of 85 patients treated with aCRP21 6 developed a conversion to either hori-zontal canal BPPV or anterior canal BPPV

Semont maneuver for BPPV One Class II study6

showed that patients treated with Semont maneu-ver were ldquosignificantlyrdquo improved compared withthose treated with a sham maneuver A Class IIIstudy22 randomized 156 patients to Semont ma-neuver medical therapy (flunarizine 10 mgdayfor 60 days) or no treatment At 6-month follow-up 942 of patients treated with Semont ma-neuver reported symptom resolution vs 577 ofpatients treated with flunarizine and 346 of pa-tients who received no treatment

A Class IV study23 comparing Semont maneu-ver and a CRP either with or without post-treatment instructions found success rates for allgroups ranging from 88 to 96 with no differ-ences between groups Another Class IV study24

compared patients randomized to treatment withCRP Semont maneuver or BrandtndashDaroff exer-cises Symptom resolution among those treatedwith either CRP or Semont maneuver at 1 weekwas the same (74 vs 71 24 for BrandtndashDaroff exercises) At 3-month follow-up 93 ofpatients treated with CRP were asymptomatic vs

77 of those treated with Semont maneuver (p 0027) 62 of patients treated with BrandtndashDaroff exercises were asymptomatic at 3 months

Conclusion Two Class I studies and three ClassII studies have demonstrated a short-term (1 dayto 4 weeks) resolution of symptoms in patientstreated with the CRP with NNT ranging from143 to 37 The Semont maneuver is possiblymore effective than no treatment (Class III) asham treatment (Class II) or BrandtndashDaroff exer-cises (Class IV) as treatment for posterior canalBPPV Two Class IV studies comparing CRP withSemont maneuver have produced conflicting re-sults one showed no difference between groupsand the other showed a lower recurrence rate inpatients undergoing CRP

Recommendation (appendix e-3) Canalith reposi-tioning procedure is established as an effectiveand safe therapy that should be offered to patientsof all ages with posterior semicircular canal BPPV(Level A recommendation) The Semont maneu-ver is possibly effective for BPPV but receives onlya Level C recommendation based on a singleClass II study Although many experts believethat the Semont maneuver is as effective as cana-lith repositioning maneuver based on currentlypublished articles the Semont maneuver can onlybe classified as ldquopossibly effectiverdquo There is in-sufficient evidence to establish the relative effi-cacy of the Semont maneuver to CRP (Level U)

Question 2 Which maneuvers are the most effectivetreatments for horizontal canal and anterior canalBPPV Horizontal canal BPPV Horizontal canalBPPV accounts for 10 to 17 of BPPV25-29

though some reports have been even higher3031

The nystagmus of horizontal canal BPPV is hori-zontal and changes direction when the head isturned to the right or left while supine (direction-changing paroxysmal positional nystagmus) Thedirection-changing positional nystagmus may beeither geotropic or apogeotropic31 The geotropicform which is thought to result from free-movingotoconial debris in the long arm of the semicircularduct is generally more responsive to treatment Theapogeotropic form is likely due to otoconial mate-rial in the short arm of the canal or attached to thecupula (cupulolithiasis)2432 Hence one seeks toconvert the more treatment-resistant apogeotropicto the more treatment-responsive geotropic nystag-mus form of horizontal canal BPPV3233

The nystagmus and vertigo of horizontal canalBPPV may be provoked by the DixndashHallpike ma-neuver but are more reliably induced by the su-pine head roll test or so-called PagninindashMcCluremaneuver (figure 4)34-36 The methods used to de-

Figure 3 Semont maneuver for right-sided benign paroxysmal positional vertigo

While sitting up in Step 1 the patientrsquos head is turned 45 degrees toward the left side andthen the patient is rapidly moved to the side-lying position as depicted in Step 2 This positionis held for 30 seconds or so and then the patient is rapidly taken to the opposite side-lyingposition without pausing in the sitting position or changing the head position relative to theshoulder This is in contrast to the BrandtndashDaroff exercises that entail pausing in the sittingposition and turning the head with body position changes


termine the affected side in horizontal canal BPPVare described elsewhere303738e1 CRP or modifiedEpley maneuvers are usually ineffective for hori-zontal canal BPPV2134 so a number of alternativemaneuvers have been devised

Variations of the roll maneuver (Lempert ma-neuver or barbecue roll maneuver) (figure 5) are

the most widely published treatments for hori-zontal canal BPPV2526293132343638e1e2 Success intreatment based on all Class IV studies is proba-bly 7532e2 but ranges from approximately50 to nearly 100 However the studies useddiffering and sometimes unclear endpoints andmany lacked control groups to allow comparisonbetween the treatment and the natural rate of res-olution of this condition

The Gufoni maneuver is another techniquethat has been reported as effective in treating hor-izontal canal BPPVe3 (figure e-3 A and B) Severalstudies all Class IV have reported success usingthis or a similar maneuver for horizontal canalBPPV for both the geotropic and apogeotropicnystagmus forms323338e4 Similarly the Vannuc-chindashAsprella liberatory maneuver may be effec-tive but there is only limited Class IV datasupporting its use38e5e6 Casani et al32 and Appianiet al33 review other techniques used with success inthe treatment of both the geotropic and apogeotro-pic forms of horizontal canal BPPV

Another treatment reported as effective303236e2e7

is referred to as forced prolonged positioning Withthis method the patient lies down laterally to theaffected side and the head is then turned 45 degreestoward the ground and maintained in that positionfor 12 hours before the patient is returned to thestarting position Some authors advocate this tech-nique for refractory horizontal canal BPPV32e3 Us-ing this approach one Class IV study reportedremission rates of 75 to 9032

Anterior canal BPPV Anterior canal BPPV is usu-ally transitory and most often is the result of ldquoca-nal switchrdquo that occurs in the course of treatingother more common forms of BPPV21

We identified only two studies specifically ad-dressing the treatment of anterior canal BPPVboth were Class IV studiese8e9 Success rates werebetween 92 and 97 though there were nocontrols to determine whether this represents animprovement over the natural history of this fre-quently self-resolving form of BPPV

Conclusion Based on Class IV studies variationsof the Lempert supine roll maneuver the Gufonimethod or forced prolonged positioning seemmod-erately effective for horizontal canal BPPVTwoun-controlled Class IV studies report high responserates to maneuvers for anterior canal BPPV

Recommendation None (Level U)

Question 3 Are postmaneuver activity restrictionsnecessary after canalith repositioning procedure Inone Class I study2 and one Class II4 study demon-strating the benefit of CRP patients wore a cervi-cal collar for 48 hours and avoided sleeping on the

Figure 4 Supine roll test (PagninindashMcClure maneuver) to detect horizontal canalbenign paroxysmal positional vertigo (BPPV)

The patient may be taken from sitting to straight supine position (1) The head is turned to theright side (2) with observation of nystagmus and then turned back to face up (1) Then thehead is turned to the left side (3) The side with the most prominent nystagmus is taken to bethe affected horizontal semicircular canal The direction of nystagmus in each position deter-mines whether the horizontal canal BPPV is of the geotropic or apogeotropic type

Figure 5 Lempert roll maneuver for right-sided horizontal canal benignparoxysmal positional vertigo (BPPV)

When it is determined to be horizontal canal BPPV affecting the right side the patient is takenthrough a series of step-wise 90-degree turns away from the affected side in Steps 1through 5 holding each position for 10 to 30 seconds From Step 5 the patient positions hisor her body to the back (6) in preparation for the rapid and simultaneous movement from thesupine face up to the sitting position (7)


affected side for 1 week One Class I study3 andtwo Class II studies56 that demonstrated the ben-efit of CRP used no post-treatment restrictions orinstructions These studies were not designed todetermine whether such restrictions affect treat-ment success however there seems to be little dif-ference in the rate of treatment success whether ornot restrictions were included

Six Class IV studies comparing CRP with andwithout post-treatment activity restriction wereidentified23e10-e14 Five studies23e10-e13 showed noadded benefit from post-treatment activity re-striction or positions Only one study showed aminimal benefit in patients with post-activity re-strictions as measured by the number of maneu-vers required to produce a negative DixndashHallpikemaneuvere14

Conclusion and recommendation Five Class IVstudies support the omission of post-treatmentactivity restrictions one study supports the use ofpost-treatment restrictions There is insufficientevidence to determine the efficacy of post-maneuver restrictions in patients treated withCRP (Level U)

Question 4 Is it necessary to include mastoid vibrationwith repositioning maneuvers Mastoid vibrationwas included in the original Epley repositioningmaneuver One Class II studye15 comparing pa-tients with posterior canal BPPV treated by ldquoap-propriate canalith repositioning maneuversrdquoperformed with and without vibration showedno difference in immediate symptom resolutionor relapse rate between groups

A Class III studye16 compared patients treatedby CRP with and without mastoid vibrationThere was no difference in symptom relief be-tween the groups at 4 to 6 weeks (p 068)

Two Class IV studiese17e18 showed no differ-ence in the rate of symptom resolution betweenpatients treated by a CRP with or without mas-toid vibration A third Class IV study9 reportedthat of patients treated by a CRP with vibration92 were ldquoimprovedrdquo vs 60 improvementwith CRP alone

Conclusion and recommendationOneClass II oneClass III and two Class IV studies showed noadded benefit when mastoid vibration was addedto a CRP as treatment for posterior canal BPPVMastoid oscillation is probably of no added bene-fit to patients treated with CRP for posterior ca-nal BPPV (Level C recommendation)

Question 5 What is the efficacy of BrandtndashDaroffexercises habituation exercises or patient self-administered treatments for BPPV A Class II studythat randomized patients to a CRP a ldquoliberatory

maneuverrdquo BrandtndashDaroff exercises ldquohabituationexercisesrdquo or a sham treatment found that patientstreatedwith habituation exercises did no better thanthose treated with a sham procedure6 Patientstreated with BrandtndashDaroff exercises did worsethan those treated with CRP or liberatory maneu-vers but were not compared with sham-treatedpatients

A Class IV study24 compared BrandtndashDaroffexercises performed three times daily with theSemont maneuver or CRP Patients treated withmaneuvers were pretreated with diazepam andgiven postmaneuver activity restrictions patientstreated with BrandtndashDaroff exercises were notCompliance with the exercises was not recordedAt 1-week follow-up 24 of patients treatedwith BrandtndashDaroff exercises were symptom freevs 74 of those treated with the Semont maneu-ver or CRP Given the limitations of the study itsvalidity is questionable

Three Class IV studies investigated the effi-cacy of patient-administered treatment forBPPV using various techniques One studyfound 88 improvement of BPPV when treatedwith CRP and home CRP compared with 69improvement in those only treated with CRPoncee19 Another study reported improved reso-lution of nystagmus among patients that self-administered CRP (64 recovery) vs self-administered BrandtndashDaroff exercises (23)e20

The third study found that 95 had resolutionof positional nystagmus 1 week after self-treatment with CRP vs 58 of self-treatmentwith a modified Semont maneuvere21

Conclusion and recommendation One Class II andone Class IV study suggest that BrandtndashDaroffexercises or habituation exercises are less effectivethan CRP in the treatment of posterior canalBPPV Self-administered BrandtndashDaroff exercisesor habituation exercises are less effective thanCRP in the treatment of posterior canal BPPV(Level C) There is insufficient evidence to recom-mend or refute self-treatment using Semont ma-neuver or CRP for BPPV (Level U)

Question 6 What is the efficacy of medication treat-ments for BPPV One Class III studye22 found nodifference between lorazepam 1 mg three timesdaily diazepam 5 mg three times daily or pla-cebo over the 4-week study period Another ClassIII study21 found that flunarizine was more effec-tive than no treatment but less effective than Se-mont maneuver in eliminating symptoms Thereare no randomized controlled trials of meclizine


or other drugs used for motion sickness in thetreatment of BPPV

Conclusion and recommendation A single Class IIIstudy did not demonstrate that lorazepam or di-azepam hastened resolution of symptoms inBPPV A single Class III study demonstrated somebenefit of flunarizine a drug that is unavailable inthe United States in BPPV There is no evidenceto support a recommendation of any medicationin the routine treatment for BPPV (Level U)

Question 7 What are the safety and efficacy of sur-gical treatments for posterior canal BPPV All stud-ies of surgical treatment for refractory BPPV areClass IV The most common procedure is fenes-tration and occlusion of the posterior semicircu-lar canal Five studies e23-e27 with a total of 86patients undergoing canal occlusion reportedldquocomplete reliefrdquo of BPPV symptoms in 85 as as-certained by the treating surgeon Reported com-plications included a ldquomildrdquo conductive hearingloss for 4 weeks or less ldquomildrdquo and ldquotransientrdquounsteadiness in most patients and a high fre-quency sensorineural hearing loss in 6 patients

In a Class IV study of singular neurectomyas a treatment for intractable BPPVe28 968were reported to have ldquocomplete reliefrdquo severesensorineural hearing loss occurred in 37 ofpatients

Conclusion and recommendation Six unblindedretrospective Class IV studies report relief fromsymptoms of BPPV in nearly every patient under-going posterior semicircular canal occlusion orsingular neurectomy Because the studies areClass IV they do not provide sufficient evidenceto recommend or refute posterior semicircular ca-nal occlusion or singular neurectomy as treatmentfor BPPV (Level U)

RECOMMENDATIONS FOR FUTURE RE-SEARCH Class I studies are needed to clarify thebest treatments for horizontal canal BPPV Futurestudies on these topics should adhere to theConsolidated Standards of Reporting Trials(CONSORT) criteria using validated clinicallyrelevant outcomes

PROGNOSIS AND RECURRENCE RATE The re-lapse rate and second recurrence rate of BPPV arenot fully established Short-term relapse rates rangefrom 7 to nearly 23 within a year of treatmentbut long-term recurrences may approach 50 de-pending on the age of the patient e29-e32

DISCLOSUREThe authors report the following disclosures Dr Fife hasreceived research support from GlaxoSmithKline and esti-

mates that 6 of his time is spent on canalith repositioningprocedures Dr Iverson has nothing to disclose Dr Lempertestimates that 5 of his time is spent on videooculogra-phy Dr Furman holds stock options in Neurokinetics hasreceived research support from Merck has served as an ex-pert witness on vestibular function and estimates that 1 ofhis time is spent on the Epley maneuver Dr Baloh estimates5 of his time is spent on ENG Dr Tusa estimates that 5of his time is spent on quantified positional testing Dr Hainestimates that 5 of his time is spent on ENG and 5 onVEMP Dr Herdman received research support fromVAMC and served as an expert witness on the Hallpike-Dixmaneuver Dr Morrow has received honoraria from Bio-genIdec and has served as an expert witness and consultanton medico-legal proceedings Dr Gronseth has receivedspeaker honoraria from Pfizer GlaxoSmithKline andBoehringer Ingelheim and served on the IDMC Committeeof Ortho-McNeil

DISCLAIMERThis statement is provided as an educational service of theAmerican Academy of Neurology It is based on an assess-ment of current scientific and clinical information It isnot intended to include all possible proper methods ofcare for a particular neurologic problem or all legitimatecriteria for choosing to use a specific procedure Neither isit intended to exclude any reasonable alternative method-ologies The American Academy of Neurology recognizesthat specific patient care decisions are the prerogative ofthe patient and the physician caring for the patient basedon all of the circumstances involved

Received August 1 2007 Accepted in final form February23 2008

REFERENCES1 von Brevern M Radtke A Lezius F et al Epidemiol-

ogy of benign paroxysmal positional vertigo a popula-tion based study J Neurol Neurosurg Psychiatr 200778710ndash715

2 Lynn S Pool A Rose D Brey R Suman V Random-ized trial of the canalith repositioning procedure Oto-laryngol Head Neck Surg 1995113712ndash720

3 von Brevern M Seelig T Radtke A Tiel-Wilck KNeuhauser H Long-term efficacy of Epleyrsquos manoeu-vre a double-blind randomized trial J Neurol Neuro-surg Psychiatr 200677980ndash982

4 Froehling DA Bowen JM Mohr DN et al The cana-lith repositioning procedure for the treatment of be-nign paroxysmal positional vertigo a randomizedcontrolled trial Mayo Clin Proc 200075695ndash700

5 Yimtae K Srirompotong S Srirompotong S Sae-SeawP A randomized trial of the canalith repositioning pro-cedure Laryngoscope 2003113828ndash832

6 Cohen HS Kimball KT Effectiveness of treatments forbenign paroxysmal positional vertigo of the posteriorcanal Otol Neurotol 2005261034ndash1040

7 Schulz KF Grimes DA Allocation concealment in ran-domised trials defending against deciphering Lancet2002359614ndash618


8 Sherman D Massoud EA Treatment outcomes of be-nign paroxysmal positional vertigo J Otolaryngol200130295ndash299

9 Li JC Mastoid oscillation a critical factor for successin canalith repositioning procedure Otolaryngol HeadNeck Surg 1995112670ndash675

10 Blakley BW A randomized controlled assessment ofthe canalith repositioning maneuver OtolaryngolHead Neck Surg 1994110391ndash396

11 Lempert T Wolsley C Davies R et al Three hundredsixty-degree rotation of the posterior semicircular ca-nal for treatment of benign positional vertigo aplacebo-controlled trial Neurology 199749729ndash733

12 Wolf M Hertanu T Novikov I Kronenberg J Epleyrsquosmanoeuvre for benign paroxysmal positional vertigo aprospective study Clin Otolaryngol 19992443ndash46

13 Asawavichianginda S Isipradit P Snidvongs K et alCanalith repositioning for benign paroxysmal posi-tional vertigo a randomized controlled trial Ear NoseThroat J 200079732ndash734

14 Angeli SI Hawley R Gomez O Systematic approachto benign paroxysmal positional vertigo in the elderlyOtolaryngol Head Neck Surg 2003128719ndash725

15 Sridhar S Panda N Particle repositioning manoeuvrein benign paroxysmal positional vertigo is it reallysafe J Otolaryngol 20053441ndash45

16 Chang AK Schoeman G Hill M A randomized clini-cal trial to assess the efficacy of the Epley maneuver inthe treatment of acute benign positional vertigo AcadEmerg Med 200411918ndash924

17 Lopez-Escamaez J Gonzalez-Sanchez M Salinero JMeta-analysis of the treatment of benign paroxysmalpositional vertigo by Epley and Semont maneuversActa Otorrinolaringol Esp 199950366ndash370

18 Woodworth BAGillespieMB Lambert PR The canalithrepositioning procedure for benign positional vertigo ameta-analysis Laryngoscope 20041141143ndash1146

19 Teixeira LJ Machado JN Maneuvers for the treat-ment of benign positional paroxysmal vertigo a sys-tematic review Rev Bras Otorrinolaringol (Engl Ed)200672130ndash139

20 Hilton M Pinder D The Epley manoeuvre for benignparoxysmal positional vertigo a systematic reviewClin Otolaryngol Allied Sci 200227440ndash445

21 Herdman SJ Tusa RJ Complications of the canalithrepositioning procedure Arch Otolaryngol Head NeckSurg 1996122281ndash286

22 Salvinelli F Casale M Trivelli M et al Benign parox-ysmal positional vertigo a comparative prospectivestudy on the efficacy of Semontrsquos maneuver and notreatment strategy Clin Ter 20031547ndash11

23 Massoud EA Ireland DJ Post-treatment instructionsin the nonsurgical management of benign paroxysmalpositional vertigo J Otolaryngol 199625121ndash125

24 Soto Varela A Bartual Magro J Santos Perez S et alBenign paroxysmal vertigo a comparative prospectivestudy of the efficacy of Brandt and Daroff exercisesSemont and Epley maneuver Rev Laryngol Otol Rhi-nol (Bord) 2001122179ndash183

25 White JA Coale KD Catalano PJ Oas JG Diagnosisand management of horizontal semicircular canal be-nign paroxysmal positional vertigo Otolaryngol HeadNeck Surg 2005133278ndash284

26 Prokopakis EP Chimona T Tsagournisakis M etal Benign paroxysmal positional vertigo 10-year ex-perience in treating 592 patients with canalith repo-sitioning procedure Laryngoscope 20051151667ndash1671

27 Caruso G Nuti D Epidemiological data from 2270PPV patients Audiological Med 200537ndash11

28 Leopardi G Chiarella G Serafini G et al Paroxysmalpositional vertigo short- and long-term clinical andmethodological analyses of 794 patients Acta Otolar-yngol Ital 200323155ndash160

29 Fife TD Recognition and management of horizontalcanal benign positional vertigo Am J Otol 199819345ndash351

30 Koo JW Moon IJ Shim WS Moon SY Kim JS Valueof lying-down nystagmus in the lateralization of hori-zontal semicircular canal benign paroxysmal positionalvertigo Otol Neurol 200627367ndash371

31 Nuti D Agus G Barbieri M-T Passali D The manage-ment of horizontal-canal paroxysmal positional ver-tigo Acta Otolaryngol 1998118455ndash460

32 Casani AP Vannucchi G Fattori B Berrettini S Thetreatment of horizontal canal positional vertigo ourexperience in 66 cases Laryngoscope 2002112172ndash178

33 Appiani GC Catania G Gagliardi M Cuiuli G Repo-sitioning maneuver for the treatment of the apogeotro-pic variant of horizontal canal benign paroxysmalpositional vertigo Otol Neurotol 200526257ndash260

34 Lempert T Tiel-Wilck K A positional maneuver fortreatment of horizontal-canal benign positional ver-tigo Laryngoscope 1996106476ndash478

35 McClure JA Horizontal canal BPV J Otolaryngol19851430ndash35

36 Appiani GC Gagliardi M Magliulo G Physical treat-ment of horizontal canal benign positional vertigo EurArch Otorhinolaryngol 1997254326ndash328

37 Han BI Oh HJ Kim JS Nystagmus while recumbentin horizontal canal benign paroxysmal positional ver-tigo Neurology 200666706ndash710

38 Asprella Libonati G Diagnostic and treatment strategyof the lateral semicircular canal canalolithiasis ActaOtorhinolaryngol Ital 200525277ndash283



T D Fife D J Iverson T Lempert et al American Academy of Neurology

evidence-based review) Report of the Quality Standards Subcommittee of the Practice Parameter Therapies for benign paroxysmal positional vertigo (an


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Practice Parameter Therapies for benignparoxysmal positional vertigo(an evidence-based review)Report of the Quality Standards Subcommittee of the AmericanAcademy of Neurology

TD Fife MDDJ Iverson MDT Lempert MDJM Furman MDPhD

RW Baloh MDRJ Tusa MD PhDTC Hain MDS Herdman PT PhDFAPTA

MJ Morrow MDGS Gronseth MD

INTRODUCTION Benign paroxysmal positionalvertigo (BPPV) is a clinical syndrome character-ized by brief recurrent episodes of vertigo trig-gered by changes in head position with respect togravity BPPV is the most common cause of recur-rent vertigo with a lifetime prevalence of 241

The term BPPV excludes vertigo caused by le-sions of the CNS BPPV results from abnormalstimulation of the cupula within any of the threesemicircular canals (figure e-1 on theNeurologyreg

Web site at wwwneurologyorg) most cases ofBPPV affect the posterior canal The cupular exci-tatory response is usually related to movement ofotoliths (calcium carbonate crystals) that create acurrent of endolymph within the affected semicir-cular canal The most common form of BPPV oc-curswhen otoliths from themacula of the utricle fallinto the lumen of the posterior semicircular canalresponding to the effect of gravity These ectopicotoliths which have been observed intraoperativelyare referred to as canaliths The canaliths are denseand move in the semicircular canal when the headposition is changedwith respect to gravity the cana-lith movement ultimately deflects the cupula lead-ing to a burst of vertigo and nystagmus In somecases canaliths adhere to the cupula causing cupu-lolithiasis which is a form of BPPV less responsiveto treatment maneuvers

Typical signs of BPPV are evoked when thehead is positioned so that the plane of the affectedsemicircular canal is spatially vertical and thus

aligned with gravity This produces a paroxysmof vertigo and nystagmus after a brief latency Po-sitioning the head in the opposite direction re-verses the direction of the nystagmus Theseresponses often fatigue upon repeat positioningThe duration frequency and intensity of symptomsof BPPV vary and spontaneous recovery occurs fre-quently Table e-1 outlines the characteristics ofBPPV by canal type

Repositioning maneuvers are believed to treatBPPV by moving the canaliths from the semicir-cular canal to the vestibule from which they areabsorbed There are a number of repositioningmaneuvers in use but they lack standardizationThe figures and Web-based video clips do not in-clude all variations but represent those maneuversand treatments used in the Class I and Class IIstudies that are reviewed as well as several othersin common use

This practice parameter seeks to answer the fol-lowing questions 1) What maneuvers effectivelytreat posterior canal BPPV 2)Whichmaneuvers areeffective for anterior and horizontal canal BPPV 3)Are postmaneuver restrictions necessary 4) Is con-current mastoid vibration important for efficacy ofthe maneuvers 5) What is the efficacy of habitua-tion exercises BrandtndashDaroff exercises or patientself-administered treatmentmaneuvers 6) Aremed-ications effective for BPPV 7) Is surgical occlusionof the posterior canal or singular neurectomy effec-tive for BPPV

Supplemental data atwwwneurologyorg

Address correspondence andreprint requests to theAmerican Academy ofNeurology 1080 MontrealAve St Paul MN 55116guidelinesaancom

GLOSSARYAAN American Academy of Neurology BPPV benign paroxysmal positional vertigo CONSORT Consolidated Stan-dards of Reporting Trials CRP canalith repositioning procedure NNT number needed to treat

From the Barrow Neurological Institute and University of Arizona College of Medicine (TDF) Phoenix AZ Humboldt NeurologicalMedical Group Inc (DJI) Eureka CA Department of Neurology (TL) Schlosspark-Klinik Berlin Germany Department ofOtolaryngology (JMF) University of Pittsburgh PA Department of Neurology (RWB) Reed Neurological Research Center Universityof California Los Angeles CA Departments of Neurology (RJT) and Rehabilitation Medicine (SH) Emory University Atlanta GANorthwestern University (TCH) Chicago IL Providence Multiple Sclerosis Center (MJM) Portland OR and University of Kansas(GSG) Kansas City KS

Approved by the Quality Standards Subcommittee on May 1 2007 by the Practice Committee on June 21 2007 and by the AmericanAcademy of Neurology Board of Directors in July 2007

QSS Subcommittee members AAN classification of evidence Classification of recommendations Conflict of Interest Statement MissionStatement of the QSS and references e1ndashe32 are available as supplemental data on theNeurologyreg Web site at wwwneurologyorg

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

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