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Three Part Question

[In adults with benign paroxysmal positional vertigo] [what treatment is most effective] at [symptom resolution]?

Clinical Scenario

A 34-year-old female comes to the emergency department due to acute episodes of dizziness. The history and physical exam are most consistent with diagnosis of posterior canal benign paroxysmal positional vertigo (BPPV). You wonder what is the most effective treatment at resolving her symptoms.

Search Strategy

Medline 1966-01/24 using PubMed, Cochrane Library (2023), and Embase
[(benign paroxysmal positional vertigo) AND (drug therapy OR patient positioning)]. Limit to English language

Search Outcome

216 articles were identified; four systematic reviews, published in the past year, addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Sharif S.,et al. May 2023 Ontario, Canada	Five RCTs, enrolling 296 patients	Systematic review	Symptom resolution	CRMs may improve symptom resolution at the point of longest follow-up as when compared to vestibular suppressants (relative risk [RR] 0.63)	Only 296 participants the included trials, leading to very low to low certainty of evidence. None of the included studies assessed the ability of an emergency physician to perform CRMs adequately. All of the included studies had a high risk of bias and clinical heterogeneity.
			Repeat ED/clinic visits	Vestibular suppressants had an uncertain effect (RR 0.37)
			Patient satisfaction	Vestibular suppressants had an uncertain effect
			Quality of life	Vestibular suppressants had an uncertain effect
			Adverse events	Vestibular suppressants had an uncertain effect
Khoujah D et al April 2023 USA	Seven systematic reviews	Systematic review of systematic reviews and meta-analysis of individual studies	Complete resolution of vertigo at 1 week	Epley (compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19)	Total number of patients included in the individual RCTs was low. Included studies enrolled patients in outpatient primary and specialty clinics rather than the ED. The last SR was published in 2014, potentially missing more recent RCTs.
			Conversion to negative Dix–Hallpike at 1 week	Epley was associated with higher conversion (OR 6.67)
Saishoji Y, et al Dec 2023 Japan	Twenty-seven RCTS were included	Systematic review and meta-analysis	Reduction of subjective symptoms	Compared to control, EM reduced symptoms (RR 3.14)	Long-term effects were not evaluated. Subgroup analysis for dizziness severity, presence or absence of recurrence, and repeated EM was not performed. Experienced physicians performed EM for BPPV in the included studies.
Li W, et al March 2023 China	A total of 9 randomized controlled trials with 860 PC-BPPV patients were included, in which 432 were treated with Epley’s maneuver plus betahistine, and 428 received Epley’s maneuver alone	Systematic review and meta-analysis	Dizziness handicap inventory (DHI) score	Epley’s maneuver plus betahistine significantly improved DHI score than Epley’s maneuver alone	Total sample size was relatively small and did not provide sufficient power to estimate the efficiency and recurrence rate. Possible recall or selection bias due to study design
			Efficacy rate after treatment	No significant differences in the two groups
			Recurrence rate after treatment	No significant differences in the two groups

Comment(s)

Clinical trials, systematic reviews, and meta-analyses have supported the use of the Epley maneuver for BPPV, particularly when the condition is related to canalithiasis in the posterior semicircular canal. The Epley maneuver, also known as canalith repositioning procedure, is designed to move loose calcium carbonate crystals (otoconia) out of the affected semicircular canal, typically the posterior canal. The procedure involves a series of specific head and body movements that guide the crystals through the inner ear's fluid, ultimately repositioning them in a part of the inner ear where they do not cause symptoms. Evidence from published studies show that emergency clinicians can learn to correctly use the Epley maneuver, and the technique should be incorporated into residency programs and continuing medical education. While the evidence for the Epley maneuver is strong for posterior canal canalithiasis, it's important to note that there are different types of BPPV (e.g., involving different canals), and the maneuver may not be as effective for all variants. Growing evidence suggests that betahistine, a histamine H1 agonist and H3 antagonist, may improve vertigo when used with the Epley maneuver but has no impact on efficacy rate or recurrence.

Clinical Bottom Line

Patients with posterior canal BPPV should have canalith relocation maneuvers performed rather than vestibular suppressant medications to resolve symptoms of vertigo.

References

1. Sharif, S, Khoujah, D, Greer, A, Naples, JG, Upadhye, S, Edlow, JA. Vestibular suppressants for benign paroxysmal positional vertigo: A systematic review and meta-analysis of randomized controlled trials Academic Emergency Medicine May 2023; 30: 541- 551
2. Khoujah D, Naples JG, Silva LOJE, Edlow JA, Gerberi DJ, Carpenter CR, Bellolio F. Epley maneuver for benign paroxysmal positional vertigo: Evidence synthesis for guidelines for reasonable and appropriate care in the emergency department. Academic Emergency Medicine 2023 Apr 26
3. Saishoji Y, Yamamoto N, Fujiwara T, Mori H, Taito S. Epley manoeuvre's efficacy for benign paroxysmal positional vertigo (BPPV) in primary-care and subspecialty settings: a systematic review and meta-analysis. BMC Prim Care 2023 Dec
4. Li W, Sun J, Zhao Z, Xu J, Wang H, Ding R, Zhang Y. Efficacy of Epley's maneuver plus betahistine in the management of PC-BPPV: A systematic review and meta-analysis Medicine (Baltimore) 2023 Mar; 102(13):e33421