Practice Parameter: Simple Maneuver Is Best Therapy for Common Form of Vertigo

The most common form of vertigo is best treated with the easiest and quickest method, according to a new practice parameter issued on May 26 by the American Academy of Neurology.

Posterior canal benign paroxysmal positional vertigo (BPPV) accounts for up to 30% of all vestibular presentations to dizziness clinics and also has a lifetime prevalence of 2.4% in the general population. This form of vertigo is believed to be caused when calcium crystals found throughout the inner ear break loose and migrate into the lumen of the posterior semicircular canal. These crystals, or canaliths, then trigger abnormal stimulation of cells that signal the sensation of movement and the position of the head, resulting in vertigo.

To treat BPPV, many physicians have used a series of maneuvers that turn a patient's head in different directions, allowing gravity to draw the canaliths from the posterior semicircular canal to the vestibule, where they are absorbed. Several maneuvers have been used since the early 1990s, but their validity remained in question because it took years for enough evidence to accumulate to permit rigorous evaluation, said Terry D. Fife, MD, lead author of the practice parameter and an assistant professor of clinical neurology at the University of Arizona College of Medicine and the Barrow Neurological Institute in Phoenix.

“It took a period of time before we achieved a critical mass of scientific papers, but now we could begin to give definitive answers to what works, what doesn’t, and what needs further research,” Fife said.

Diagnosis of BPPV typically begins with a procedure called the Dix-Hallpike maneuver, which differentiates peripheral from central vertigo. Once the diagnosis is confirmed, including which ear is involved, evidence indicates that a canalith repositioning procedure, also known as the Epley maneuver, is a safe and effective treatment for the problem, according to the practice parameter (Fife TD et al. Neurology. 2008;70[22]:2067-2074). The Semont maneuver, another repositioning procedure popular in Europe, was classified as only possibly effective due to a lack of rigorous clinical trials demonstrating its benefit. The authors also noted that there was insufficient evidence to recommend or refute the effectiveness of patients performing the maneuver themselves at home, but said that it probably would do no harm.

In addition, the authors said they could not recommend any medications, such as lorazepam or diazepam, for the routine treatment of BPPV due to a lack of evidence of efficacy. A small study found that flunarizine (not available in the United States) was more effective than no treatment in eliminating symptoms but it was less effective than the Semont maneuver.

The authors also explained that some studies found benefit of surgical procedures to treat BPPV—fenestration and occlusion of the posterior semicircular canal and singular neurectomy. But they said they could not recommend or refute such surgical treatments because the studies were small, unblinded, and retrospective.

As for posttreatment care, the authors said there was insufficient evidence to determine the efficacy of activity restrictions such as the wearing of a cervical collar for 48 hours or avoiding sleeping on the affected side for 1 week.

Successfully eliminating BPPV will probably not be a singular event; relapse and second recurrence rates range from 7% to almost 23% within a year following treatment. Long-term recurrence rates may approach 50%, depending on age.

The practice parameter shows that physicians in general practice could be easily trained to diagnose BPPV and perform the Epley maneuver, avoiding the need for referrals or costly imaging tests, said Fife.

“If you're going to add something to your repertoire, this has a high reward for physicians and for patients,” Fife said. “How many treatments do we have where you can come in with a condition, have it treated in 15 minutes, and then it's gone and you don't need a pill or have to spend a lot of money?”

Neil Bhattacharyya, MD, associate chief, Division of Otolaryngology at Brigham and Women's Hospital in Boston, called the practice parameter “quite good,” but said it addressed only 1 part of a physician's interaction with a patient having vertigo and cautioned against expanding the Epley maneuver to the general physician population. “Before one treats a patient, we need to know that the clinician made a correct diagnosis,” Bhattacharyya said. “And while the maneuvers look simple, there are some subtleties, and studies need to be done to see if the primary care physicians are getting similar success rates as seen in clinical trials.”

Bhattacharyya is chairing a BPPV clinical practice guideline panel for the American Academy of Otolaryngology–Head and Neck Surgery. He said the guideline, expected to be completed in November, will incorporate a substantial portion of the practice parameter but will also make recommendations based on the best available science for diagnosis, testing, and follow-up care. Members of the American Academy of Neurology, American College of Physicians, American College of Emergency Physicians, the American Chiropractic Association, and other groups are serving on the guideline panel.