What are the recommended management strategies for benign paroxysmal positional vertigo (BPPV) in primary care?

Recommended management strategies for benign paroxysmal positional vertigo (BPPV) in primary care include:

• Discuss watchful waiting: Offer the option of observation without immediate treatment as symptoms may settle spontaneously.
• Particle repositioning manoeuvres: If the person prefers treatment, offer a canalith repositioning procedure such as the Epley manoeuvre ideally at first presentation if expertise and time allow. This manoeuvre involves specific head and body movements to reposition otoliths and can improve symptoms shortly after treatment, though full recovery may take days to weeks.
• Repeat treatment: If symptoms persist after one week and diagnosis is certain, consider repeating the Epley manoeuvre.
• Alternative manoeuvres: The Semont manoeuvre is an alternative if skills are available but is less commonly used in primary care.
• Home exercises: Suggest Brandt-Daroff exercises for home use, especially if immediate repositioning manoeuvres are not feasible.
• Safety precautions: Be cautious performing repositioning manoeuvres in people with neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, or morbid obesity. Seek specialist advice or refer if in doubt.
• Symptomatic drug treatment: Generally not helpful for BPPV and not routinely recommended.
• Follow-up: Advise the person to return for review if symptoms have not resolved after 4 weeks to reassess diagnosis and management.

During manoeuvres, advise the person they may experience transient vertigo and ensure head positions are maintained for at least 30 seconds, waiting for vertigo to subside before moving. Movements should ideally be rapid but can be performed slowly if necessary, especially in older adults. There is usually no need to impose positional restrictions after the procedure.

A video demonstration of the Epley manoeuvre may aid understanding and adherence.

These recommendations are based on expert opinion and clinical guidelines including the American Academy of Otolaryngology - Head and Neck Surgery Foundation and UK clinical knowledge summaries.

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