Diagnosis and Treatment of BPPV

BPPV stands for Benign Paroxysmal Positional Vertigo.  In the context of BPPV, the term “benign” is used to describe the condition as it is not due to any serious disorder and there is an overall favourable prognosis for recovery.  In fact, BPPV can recover spontaneously– for approximately 20% of patients by 1 month and up to 50% at 3 months (Lynn et al, 1995; Bruton et al 2012).  This is not to make light of this condition.  For many, it can have a profound effect on their quality of life and it also represents a significant falls risk.   Because of this, early diagnosis is key.   

A diagnosis of BPPV is based on the clinical history and physical exam.  When a patient describes a history of vertigo, lasting less than a minute, provoked by changes in head position in relation to gravity, BPPV would be suspected.  Once the physio has gathered enough information from the patient about the history of their symptoms, a thorough physical exam is carried out to rule out other disorders and to confirm the suspicion of BPPV.  These tests are all easily performed in the clinic. 

Routine radiographic imaging, for example MRI or CT techniques, is not useful in the diagnosis of BPPV, because there are no radiological findings characteristic of, or diagnostic for BPPV (Bhattacharyya et al, 2018).  If, however, a patient presents with a clinical history compatible with BPPV but also have other neurological signs or symptoms that are not normally seen in BPPV, or if a patient is not responding to treatment as expected, radiographic imaging would be considered.    

Once BPPV has been diagnosed, treatment can begin immediately.  BPPV is treated using canalith repositioning manoeuvres.  The manoeuvres are designed to get rid of the debris causing the problem in the semicircular canal.  The type of manoeuvre used depends on which of the canals are affected.  There is very strong evidence supporting the efficacy of these manoeuvres with studies showing over 90% of patients either improved or were symptom free after a single manoeuvre (Herdman et al, 1993; Gaur et al 2015).   

Occasionally, BPPV will be present alongside another vestibular condition.  When this occurs, a patient will often report that their symptoms on head movements have improved but they are still feeling a sense of imbalance or general dizziness.  If this is the case, further vestibular rehabilitation in the form of an exercise programme may be needed to treat the underlying condition. 

The literature shows that nearly 50% of patients experience at least one recurrence in the 2 years after treatment with canalith repositioning manouever (De Stefano et al, 2013).  In my experience, patients tend to find subsequent episodes less distressing, probably because they recognise the symptoms as BPPV, know the “benign” nature of the symptoms and know that it can be easily treated.  I will often advise patients that if their symptoms return, to give me a ring and book in for a follow up appointment.  Unless their symptoms are very different to the last episode, a 30 minute appointment, rather than the 1 hour initial assessment, is all that is needed.   

Medication commonly prescribed in the treatment of vertigo include serc and stemetil.  These are prescribed to reduce the sensation of spinning and the accompanying motion sickness and can be broadly termed as vestibular suppressant medications.  While these may be useful in the management of severe symptoms in the short term, they are not routinely recommended in the treatment of BPPV (Bhattacharyya et al, 2017).  Studies have shown that the canalith repositioning manoeuvre is more effective than the vestibular suppressant medication (90% recovery versus 30% at a 2 week follow up) and that the manoeuvre is more effective without the medication (Sundararajan et al, 2011). 

As mentioned in the first blog on BPPV, people with vitamin D deficiencies are more prone to BPPV.  A study in 2013 of patients with BPPV and a vitamin D deficiency, showed that vitamin D supplements can effectively improve symptoms of BPPV and have help prevent recurrence (Buki B et al, 2013).  

In my next blog, I will discuss the role of vestibular rehabilitation in the treatment of concussion.     

If you think you may benefit from vestibular rehabilitation, give me a ring on 01-8253997 or email me at info@pmcphysiotherapy.ie

If you would like to book a Vestibular Rehab assessment please click on the book online link below

Lynn S, Pool A, Rod D, Brey R, Suman V. Randomised trial of the canalith repositioning procedure. Otolayyngol Head Neck Surg. 1995;113:712-720 

Bruton MJ, Eby TL, Rosenfeld RM. Extracts from the Cochrane Library: modifications of the Epley manoeuvre for posterior canal BPPV. Otolarngol Head Neck Surg. 2012:262:507-511.   

Herdman S. J., Tusa R. J., Zee D. S., Proctor L. R., Mattox D. E. Single treatment approaches to benign paroxysmal positional vertigo. Archives of Otolaryngology: Head and Neck Surgery. 1993;119(4):450–454. 

Gaur S, Awasthi SK, Bhadouriya SK, Saxena R, Pathak VK, Bisht M. Efficacy of Epley’s Maneuver in Treating BPPV Patients: A Prospective Observational Study. Int J Otolaryngol. 2015;2015:487160. doi:10.1155/2015/487160                    

De Stefano A, Dispenza F, Suarez H, Perez-Fernandez N, Manrique-Huarte R, Ban JH, et al.  A multicentre observational study on the role of comorbidities in the recurrent episodes of BPPV.  Auris Nasus Larynx.  (2014) 41:31-6 

Bhattacharyya et al.  Clinical Practice Guideline: BPPV (Update). Otolaryngology- Head and Neck Surgery. 2017;156(3S)S1-S47 

Sundararajan I, Rangachari V, Sumathi V, Jumar K.  Epley’s manoeuvre versus Epley’s manoeuvre plus labyrinthine sedative as management of BPPV.  J Laryngol Otol. 2011;125:572-575  

Buki B, Ecker M, Junger H, Lundberg YW.  Vitamin D deficiency and BPPV.  Med Hypothesis (2013) 80:201-4