What are the recommended lifestyle modifications and treatments for patients diagnosed with benign paroxysmal positional vertigo (BPPV)?

For patients diagnosed with benign paroxysmal positional vertigo (BPPV), recommended treatments and lifestyle modifications primarily involve specific physical manoeuvres and exercises, along with observation ¹,².

Treatments:

• Observation (Watchful Waiting): This is an available option for managing BPPV ¹,².
• Canalith/Particle Repositioning Procedures: These manoeuvres are widely recommended for treating BPPV ¹,².
  • Epley Manoeuvre: This is generally preferred due to its common use and tolerability ¹,². It should be offered if a healthcare professional trained in its use is available and the patient does not have unstable cervical spine disease ³.
  • Semont Manoeuvre: This can be a suitable alternative, particularly for individuals who have difficulty extending their neck ¹,².
    • Procedure: The patient sits on a table or flat surface with their head turned away from the affected side ¹,². They then lie on the side of the affected ear with the head slightly turned up, remaining in this position for at least 20 seconds after any nystagmus stops ¹,². While holding the head and neck, the patient is moved back through the sitting position and then over to the opposite side, without turning the head, into an opposite side-lying position with the head facing down ¹,². They should remain in this position for at least 30 seconds before slowly returning to a sitting position ¹,².
    • Cautions: Exercise caution when performing the Semont manoeuvre if the person has neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, or morbid obesity ¹,². If there is any doubt about the procedure's safety, specialist advice should be sought, or the person referred to a medically qualified balance specialist ¹,².

Lifestyle Modifications / Home Exercises:

• Brandt-Daroff Exercises: Patients can be instructed on how to perform these exercises at home ¹,².
  • Procedure: The patient sits on the edge of a bed or couch with eyes closed ¹,². They quickly lie down sideways on one side with eyes closed, so they are lying on their side with the lateral aspect of their occiput resting on the bed, with the head positioned as if they are looking towards the ceiling (rotated 45 degrees upwards) ¹,². They rest in this position for at least 30 seconds until any vertigo subsides ¹,². Keeping eyes closed, they sit upright again and remain in this position for 30 seconds ¹,². This sequence is repeated on the other side ¹,². The sequence should be repeated 3–4 times until symptom-free, and 3–4 times a day until there have been 2 consecutive days without symptoms ¹,².
  • Efficacy: While an uncontrolled trial showed relief for many, a Cochrane review found better outcomes with the Epley manoeuvre compared to regular Brandt-Daroff exercises ¹,².
• Post-Manoeuvre Restrictions: A meta-analysis found no statistically significant difference in treatment efficacy between those undertaking post-manoeuvre postural restrictions and those not ¹,².

If a healthcare professional trained in the Hallpike manoeuvre or canalith repositioning manoeuvres is not available, or if the patient has unstable cervical spine disease, referral should be made in accordance with local pathways ³.