Management

Treatment & prognosis

BPPV is one of medicine’s most satisfying treatments: a mechanical problem with a mechanical cure. Repositioning manoeuvres resolve the great majority at the bedside — drugs and surgery play only supporting or last-resort roles.

Repositioning is the treatment

Trainee

Canalith repositioning procedures are first-line and are chosen by canal and mechanism. The Epley is the standard for posterior-canal BPPV (80–95% resolution in 1–3 sessions); the Semont is an equal alternative; horizontal-canal BPPV is treated by the Gufoni or Lempert, and anterior-canal BPPV by the Yacovino.1,2

  • Posterior canal80–90% of BPPVEpleySemont
  • Horizontal canal5–15% of BPPVGufoniLempert
  • Anterior canal1–2% of BPPVYacovino
First-line repositioning by canal. Confirm the canal and side first, then match the manoeuvre; the posterior canal dominates, so the Epley and Semont are the everyday workhorses. Full step-by-step technique for each lives in the Manoeuvres chapter.

Full step-by-step manoeuvres

Every repositioning manoeuvre — Epley, Semont, Lempert, Gufoni, Yacovino and more — is covered by canal, with step-by-step animations and a safety screener, in the Therapeutic Manoeuvres chapter →

Where drugs and rehabilitation fit

Vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) are generally avoided — they do not move otoconia, they impair central compensation, and they can prolong symptoms. Reserve them, and antiemetics, for short-term control of disabling nausea or anxiety that prevents a manoeuvre, then stop.3

Vestibular rehabilitation therapy (VRT) does not replace repositioning, but it helps specific patients: those with persistent imbalance, recurrent or multi-canal disease, coexisting vestibular hypofunction, or who cannot tolerate manoeuvres for cervical or physical reasons. It reduces fall risk and aids compensation.4

Surgery — the rare last resort

Fewer than 1% of patients have truly intractable BPPV. For them, posterior semicircular canal occlusion plugs the canal to stop both endolymph flow and otoconial movement, with 85–95% resolution.5 Its main risk is sensorineural hearing loss (≈10–15%). Singular neurectomy has been largely abandoned in favour of repositioning and, when needed, occlusion.

Prognosis, recurrence & education

The prognosis is excellent — most resolve rapidly, often after a single session, and recurrences respond to repeat manoeuvres. But recurrence is common: 30–50% within five years, higher with secondary BPPV, osteoporosis or vitamin D deficiency, prior neuritis or trauma.6 Counsel patients that mild disequilibrium for a few days after a successful manoeuvre is normal and self-limiting, teach recognition of recurrence and home self-treatment where appropriate, and correct modifiable risk factors — vitamin D supplementation may reduce recurrence in deficient patients.7

Key points

  • Repositioning manoeuvres are first-line and usually curative — see the Manoeuvres chapter.
  • Avoid vestibular suppressants beyond brief symptom control; they impair compensation.
  • VRT is an adjunct for residual imbalance, recurrence, or when manoeuvres aren’t feasible.
  • Surgery (canal occlusion) is needed in <1%; recurrence is 30–50% at five years.
  • Educate on recurrence and correct vitamin D deficiency where present.