What are the recommended treatment options for BPPV, and how effective are they in primary care?

Recommended treatment options for benign paroxysmal positional vertigo (BPPV) in primary care include:

• Discussing watchful waiting (observation) as an option, since symptoms may settle without treatment.
• Offering a particle repositioning manoeuvre, such as the Epley manoeuvre, ideally at the first presentation if the clinician has the expertise and time. This manoeuvre involves specific head and body movements to reposition canaliths in the inner ear and can lead to symptom improvement shortly after treatment, though full recovery may take days to weeks.
• If the Epley manoeuvre is not possible or inappropriate, consider the Semont manoeuvre as an alternative, though it is less commonly used in primary care.
• Suggesting Brandt-Daroff exercises for the patient to perform at home, especially if immediate repositioning manoeuvres cannot be done.
• Symptomatic drug treatment is generally not helpful for BPPV.
• Advise follow-up if symptoms persist beyond 4 weeks to reassess diagnosis and consider repeating manoeuvres if symptoms do not settle after 1 week.

Effectiveness when managed in primary care: The Epley manoeuvre performed in primary care is effective in resolving symptoms more quickly than observation alone, with expert opinion supporting its use. It can be safely performed in primary care if contraindications (such as neck or back problems, unstable cardiac disease, or suspected vertebrobasilar disease) are excluded. The procedure may cause transient vertigo during performance but is generally well tolerated. If expertise or safety concerns exist, referral to a medically qualified balance specialist is recommended. Overall, primary care management with repositioning manoeuvres is supported by clinical guidelines and expert consensus as an effective first-line treatment for BPPV ¹,².