Guideline sources The following summarized guidelines for the evaluation and management of benign paroxysmal positional vertigo (BPPV) are prepared by our editorial team based on guidelines from the Society for Academic Emergency Medicine (SAEM 2023), the American Physical Therapy Association (APTA 2022), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO- HNSF 2017), and the American Academy of Neurology (AAN 2017). 1 1 1 2 3 4 5 5 Definition BPPV (BPPV) is a common disorder of the inner ear characterized by repeated episodes of positional vertigo and nystagmus. 1 Epidemiology BPPV has an unknown origin but is thought to result from degeneration of the macula. Secondary causes include otoconial dislodgement due to otologic and nonotologic surgery, head trauma, or any means by which mechanical force reaches the inner ear, inner ear disorders (vestibular neuritis, Meniere's disease, and sudden sensorineural hearing loss. 5 Disease course https://web.pathway.md/diseases/recG0FmMlhKMvk2Tm 1/4 6/29/23, 3:17 AM Benign paroxysmal positional vertigo Pathway Disease course The aberrant semicircular canal signaling (canalithiasis and cupulolithiasis) results in BPPV, which causes clinical manifestations of dizziness that lasts less than 20 seconds accompanied by a lingering, nonspecific imbalance and characteristic nystagmus with Dix-Hallpike maneuver. Spontaneous resolution occurs in 25% of patients by 1 month and up to 50% at 3 months. 5 Prognosis and risk of recurrence BPPV is not associated with an increase in mortality. 1 Guidelines 1. Screening and diagnosis Differential diagnosis: Differentiate BPPV from other causes of imbalance, dizziness, and vertigo. B Assess patients with BPPV for factors modifying management, including impaired mobility or balance, CNS disorders, a lack of home support, and/or increased risk for falling. B 2. Diagnostic investigations Dix-Hallpike test: perform the Dix-Hallpike maneuver (by bringing the patient from an upright to supine position with the head turned 45 degrees to one side and the neck extended 20 degrees with the affected ear down) to elicit provoked vertigo associated with torsional, upbeating nystagmus for the diagnosis of posterior semicircular canal BPPV. Repeat the maneuver with the opposite ear down if the initial maneuver is negative. B Supine roll test: obtain a supine roll test to assess for lateral semicircular canal BPPV in patients with a history compatible with BPPV and horizontal or no nystagmus during the Dix-Hallpike maneuver. B Diagnostic imaging: As per SAEM 2023 guidelines, avoid obtaining routine MRI or MRA in adult patients with transient-episodic vestibular syndrome presenting to the emergency department and diagnosed with typical posterior canal-BPPV by a positive Dix-Hallpike test with the characteristic nystagmus. D As per AAO-HNSF 2017 guidelines, do not obtain radiographic imaging in patients meeting diagnostic criteria for BPPV without additional signs and/or symptoms warranting imaging. D Vestibular function testing: As per AAN 2017 guidelines, avoid obtaining cervical vestibular evoked myogenic potential testing for the diagnosis of BPPV. D As per AAO-HNSF 2017 guidelines, do not obtain routine vestibular testing in patients meeting diagnostic criteria for BPPV without additional vestibular signs and/or symptoms warranting https://web.pathway.md/diseases/recG0FmMlhKMvk2Tm 2/4 6/29/23, 3:17 AM Benign paroxysmal positional vertigo Pathway testing. D 3. Medical management Watchful waiting: consider offering observation with follow-up as an initial management strategy in patients with BPPV. C Vestibular suppressants: do not use vestibular suppressant medications (such as antihistamines and/or benzodiazepines) routinely in patients with BPPV. D 4. Nonpharmacologic interventions Vestibular rehabilitation: As per APTA 2022 guidelines, offer vestibular physical therapy in patients with acute, subacute, or chronic unilateral vestibular hypofunction. A Show 9 more As per AAO-HNSF 2017 guidelines, consider offering vestibular rehabilitation, either self- administered or administered by a clinician, in the treatment of patients with BPPV. C 5. Therapeutic procedures Canalith repositioning: perform a canalith repositioning procedure for the treatment of patients with posterior canal BPPV. B 6. Patient education General counseling: educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. B 7. Follow-up and surveillance Management of unresolved symptoms: evaluate patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or CNS disorders. B Serial clinical assessment: reassess patients within 1 month after an initial period of observation or treatment in order to document the resolution or persistence of symptoms. B Clinical findings Patient demographics Symptoms https://web.pathway.md/diseases/recG0FmMlhKMvk2Tm 3/4 6/29/23, 3:17 AM Benign paroxysmal positional vertigo Pathway Age > 60 Dizziness Female sex Inner ear hair cell damage Loss of balance Past medical history Nausea No prodromal vertigo Idiopathic Vertigo Migraine Vomiting Neurological exam Past surgical history Acute or recurrent ataxia Recent brain surgery References 1. Bhattacharyya N, Gubbels SP, Schwartz SR et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo Update). Otolaryngol Head Neck Surg. 2017 Mar;156 3_suppl):S1 S47. Open 2. Jonathan A Edlow, Christopher Carpenter, Murtaza Akhter et al. Guidelines for reasonable and appropriate care in the emergency department 3 GRACE 3 Acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023 May;30 5 442 486. Open 3. Terry D Fife, James G Colebatch, Kevin A Kerber et al. Practice guideline: Cervical and ocular vestibular evoked myogenic potential testing: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2017 Nov 28;89 22 2288 2296. Open 4. Courtney D Hall, Susan J Herdman, Susan L Whitney et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022 Apr 1;46 2 118 177. Open 5. Peng You, Ryan Instrum, Lorne Parnes. Benign paroxysmal positional vertigo. 2018 Dec 14;4 1 116 123.2018 Dec 14;4 1 116 123. Open 6. Marco Mandal , Lorenzo Salerni, Daniele Nuti. Benign Positional Paroxysmal Vertigo Treatment: a Practical Update. Curr Treat Options Neurol. 2019 Dec 5;21 12 66. Open 7. Takao Imai, Noriaki Takeda, Tetsuo Ikezono et al. Classification, diagnostic criteria and management of benign paroxysmal positional vertigo. Auris Nasus Larynx. 2017 Feb;44 1 1 6. Open 8. D Nuti, M Masini, M Mandala. Benign paroxysmal positional vertigo and its variants. 2016;137 241 56.2016;137 241 56. Open https://web.pathway.md/diseases/recG0FmMlhKMvk2Tm 4/4