What advice should I provide for benign paroxysmal positional vertigo?

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1 BENIGN PAROXYSMAL POSITIONAL VERTIGO Management View full scenario What advice should I provide for benign paroxysmal positional vertigo? Advise the person: Most people recover over several weeks, even without treatment, but symptoms can last much longer and may recur. A simple repositioning manoeuvre can help alleviate their symptoms in most cases. To get out of bed slowly and to avoid tasks that involve looking upwards. Advise on safety issues. Advise the person not to drive when they are dizzy, or if they might experience an episode of vertigo while driving. The Driver and Vehicle Licensing Agency state that people liable to 'sudden attacks of unprovoked or unprecipitated disabling giddiness' should stop driving. However, experts suggest that, in general, BPPV is not spontaneous or unprovoked and most people with this condition continue to drive. Workplace the person should inform their employer if their vertigo poses a risk in the workplace (for example if they use ladders, operate heavy machinery, or drive a vehicle). Falls in the home discuss the risk of falling in the home during an episode of vertigo and suggest measures to reduce this.

2 Basis for recommendation Reassurance The recommendation to reassure people with benign paroxysmal positional vertigo (BPPV) that their symptoms will resolve with time is based on the prognosis of BPPV as discussed in review articles [Lempert and von Brevern, 2005; Macleod and McAuley, 2008]. Advice on repositioning manoeuvres There is evidence from a Cochrane systematic review [Hilton and Pinder, 2004] and a subsequent systematic review [Helminski et al, 2010] that the Epley manoeuvre is more effective at treating BPPV in terms of symptom resolution and negative Hallpike test result in the short term than sham manoeuvres or no treatment. The effectiveness of the Epley manoeuvre over longer periods is unclear. A review of the literature in a specialist setting found a conversion rate with the Epley manoeuvre of 66 89%. A lower conversion rate was found in a primary care setting; perhaps because of differences in performance of the Epley manoeuvre or the presence of comorbid balance disorders [Bhattacharyya et al, 2008]. Advice on safety issues This recommendation is based on expert opinion in a US guideline on the management of BPPV [Bhattacharyya et al, 2008], guidelines from the Driver and Vehicle Licensing Agency (DVLA) [DVLA, 2010], expert opinion in review articles [Parnes et al, 2003], and from CKS expert reviewers. For detailed guidance on driving, see At a glance guide to the current medical standards of fitness to drive, available to download from

3 How should I manage benign paroxysmal positional vertigo? Discuss the option of watchful waiting to see whether symptoms settle without treatment. Explain that treatment may help the person's symptoms resolve more quickly. If the person prefers treatment: Offer a particle repositioning manoeuvre, such as the Epley manoeuvre. Ideally this should be done at the first presentation in primary care if the expertise and time are available. Symptoms may improve shortly after treatment, but full recovery can take days to a couple of weeks. If symptoms do not settle after 1 week and the diagnosis of BPPV is not in doubt, advise the person to return and consider repeating the Epley manoeuvre. The Semont manoeuvre is not recommended in primary care. There are devices available which enable the person to perform the particle repositioning manoeuvre at home, but experts have limited experience of their use and prefer to teach the person an exercise regimen if necessary. Consider suggesting Brandt-Daroff exercises which the person can do at home, particularly if the Epley manoeuvre cannot be performed immediately or is inappropriate. Symptomatic drug treatment is not usually helpful for people with BPPV. Advise the person to return for follow up in 4 weeks if symptoms have not resolved in case BPPV has been incorrectly diagnosed.

4 Epley manoeuvre Be cautious performing the Epley manoeuvre if the person has neck or back problems, or carotid stenosis. If in doubt about the safety of the procedure, seek specialist advice, or refer the person to a medically qualified balance specialist. Advise the person that they will experience transient vertigo during the manoeuvre. Stand at the side or behind the person to guide head movements. Maintain each head position for at least 30 seconds. If vertigo continues, wait until it has subsided. Ideally, movements should be rapid, within 1 second, but this is often not possible, particularly in older people. Expert opinion suggests that the procedure can be effective if movements are carried out slowly. Start with the person sitting upright with their head turned 45 degrees to the affected side, then lie them back (with their head still turned 45 degrees) until the head is dependent 30 degrees over the edge of the couch (as if performing the Hallpike manoeuvre). Wait for at least 30 seconds. Then: With the face upwards, but still tilted backwards by 30 degrees, rotate the head through 90 degrees to the opposite side. Hold the head in this position and ask the person to roll on to their side. Rotate the person's head so that they are facing obliquely downward with their nose 45 degrees below the horizontal. Sit the person up sideways while the head remains rotated and tilted to the side.

5 Rotate the head to the central position and move the chin downwards by 45 degrees. Video illustrations of performing the Epley manoeuvre are available at the Imperial College London Faculty of Medicine website. There is usually no need to advise the person of any positional restrictions after the procedure has been performed. Brandt Daroff exercises Instruct the person on how to perform these exercises at home. Advise them to: Sit on the edge of a bed or couch with the eyes closed. Lie down sideways on one side with their eyes closed so that 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. Rest in this position for at least 30 seconds, until any vertigo subsides. Keeping the eyes closed, sit upright again, and remain in this position for 30 seconds. Repeat on the other side. Repeat the sequence 3 4 times until they are symptom free. Repeat 3 4 times a day until there have been 2 consecutive days without symptoms. Basis for recommendation Observation (watchful waiting) The recommendation that observation without treatment is an option is based on an expert-consensus US guideline

6 on the management of benign paroxysmal positional vertigo (BPPV) [Bhattacharyya et al, 2008]. Epley manoeuvre The instructions on how to perform the Epley manoeuvre are based on expert opinion in review articles [Epley, 1992; Lempert et al, 1995] and CKS expert reviewers. The use of particle repositioning manoeuvres is recommended by expert consensus US guidelines on the treatment of BPPV [Bhattacharyya et al, 2008]. Most evidence is from trials looking at the use of the Epley manoeuvre in a specialist setting. There is evidence from a Cochrane systematic review [Hilton and Pinder, 2004] and a subsequent systematic review [Helminski et al, 2010] that the Epley manoeuvre is more effective at treating BPPV in terms of symptom resolution and negative Hallpike test result than sham manoeuvres or no treatment in the short term. The effectiveness of the Epley manoeuvre over longer time periods is unclear. A clinical practice guideline on BPPV also discussed evidence from additional meta-analyses and concluded that the Epley manoeuvre is significantly more effective than placebo in treating posterior canal BPPV [Bhattacharyya et al, 2008]. Evidence from a subsequent primary care study found a lower success rate with the Epley manoeuvre than studies in a specialist setting [Munoz et al, 2007]. One reason for this discrepancy may be a difference in delivery of the Epley manoeuvre between the two settings [Bhattacharyya et al, 2008]. There is limited evidence to support the use of devices which enable people with BPPV to perform particle repositioning manoeuvres at home to manage their symptoms. Expert opinion from CKS reviewers suggests

7 that they have limited experience of their use and prefer to teach the person an exercise regimen if necessary. Expert opinion in a review article suggests that symptoms usually resolve soon after treatment [Lempert and von Brevern, 2005]. A trial showed symptom resolution in 77% of people with positional vertigo after one treatment with the Epley manoeuvre, and another 20% when the treatment was repeated a week later [Epley, 1992]. A clinical practice guideline on BPPV found insufficient evidence to support the use of postural restrictions following the Epley manoeuvre [Bhattacharyya et al, 2008]. A meta-analysis of six studies included 523 people who had undergone canalith repositioning manoeuvres (Epley or Semont). Postural restrictions included wearing a neck collar, limiting head turning, and avoiding lying on the affected side. The duration of restriction varied between studies. None of the restrictions gave improvements that were statistically significant, and when the results of all restrictions were pooled, there was no advantage of restriction over no restriction [Devaiah and Andreoli, 2010]. Semont manoeuvre Although a clinical practice guideline on BPPV discussed the Semont manoeuvre (an alternative particle repositioning manoeuvre) and found some evidence to suggest it is more effective than no treatment, clinical trials are limited and comparative data are lacking [Bhattacharyya et al, 2008]. CKS expert reviewers suggest that the Semont manoeuvre is less suitable for use in primary care. This is because it is generally less well tolerated and less reliable; therefore it has not been recommended and is not described here. Brandt Daroff exercises

8 The instructions on how to perform Brandt Daroff exercises are based on expert opinion in review articles [Brandt and Daroff, 1980; Hanley et al, 2001]. Evidence from an uncontrolled trial in 67 people found that all but one person experienced relief from vertigo after performing the exercises for 3 14 days [Brandt and Daroff, 1980]. A more recent review of the literature on Brandt Daroff exercises found poor-quality evidence which suggested that Brandt Daroff exercises are less effective than the Epley manoeuvre for the treatment of posterior canal BPPV [Fife et al, 2008]. However, Brandt Daroff exercises are unlikely to do harm and can be done at home by the patient, so they are recommended on the basis of expert opinion from reviewers of the CKS topic on Vertigo. Symptomatic drug treatment A US guideline on the management of BPPV found no evidence to suggest that symptomatic drugs are a substitute for repositioning manoeuvres. Those studies that showed improvement with medication were carried out over the same period that spontaneous resolution would be expected to occur [Bhattacharyya et al, 2008]. Expert opinion in a narrative review [Hain and Uddin, 2003] and the opinion of CKS expert reviewers was consistent with this, and suggests that most drugs are not effective in treating BPPV and may have adverse effects. Follow up This recommendation is based on expert opinion in a US guideline that all people with BPPV should be followed up within 1 month [Bhattacharyya et al, 2008]. When should I admit or refer a person with benign paroxysmal positional vertigo? Admit the person to hospital if they have severe

9 nausea and vomiting and are unable to tolerate oral fluids. Refer to a medically qualified balance specialist (such as an ear, nose, and throat specialist; audiovestibular specialist physician; or care of the elderly physician with a special interest depending on local protocol) if any of the following apply: The expertise to provide the Epley manoeuvre is not available in primary care. The Epley manoeuvre has been performed and repeated, and symptoms are still present. Symptoms or signs are atypical the person may have lateral canal BPPV or another diagnosis. Symptoms and signs have not resolved in 4 weeks in case the diagnosis of BPPV is incorrect. There have been three or more periods during which the person has experienced episodes of vertigo. For more information on when to refer other people with the symptom of vertigo, including red flag features for urgent referral, see the CKS topic on Vertigo. Basis for recommendation These recommendations are based on expert opinion from: US clinical practice guidelines on the management of benign paroxysmal positional vertigo (BPPV) [Bhattacharyya et al, 2008]. A review article on the diagnosis of vertigo in general practice [Barraclough and Bronstein, 2009]. A study reporting referral patterns for dizziness in primary care [Bird et al, 1998]. Referral criteria were formulated from expert opinion for the purposes of the study.

10 A review article suggesting referral if symptoms are atypical or unresponsive to treatment [Parnes et al, 2003]. CKS expert reviewers. Referral for the Epley manoeuvre Expert opinion in review articles suggests that the Epley manoeuvre is suitable for use in primary care, which will reduce referrals to specialist centres, but that if symptoms do not resolve the person should be referred [Parnes et al, 2003; Hilton and Pinder, 2004; Cranfield et al, 2010]. CKS considers it good clinical practice to refer the person to a medically qualified balance specialist for treatment if the expertise to perform the Epley manoeuvre is not available in primary care. CKS expert reviewers suggest that if the Epley manoeuvre has been tried twice, with no resolution of symptoms, the person should be referred to exclude an alternative diagnosis. Other secondary care treatments Vestibular rehabilitation (a form of physical therapy which aims to help people compensate for deficits related to a wide range of balance disorders) is not usually used for uncomplicated BPPV [DTB, 2009]. Evidence from a Cochrane systematic review found that vestibular rehabilitation is more effective than sham interventions or control in terms of resolving dizziness, and found that particle repositioning manoeuvres are more effective at achieving complete symptom resolution in BPPV. Data were insufficient to determine which type of vestibular rehabilitation is most effective [Hillier and Holohan, 2007]. Apart from therapeutic manoeuvres, other treatments that may occasionally be used as a last resort for people with severe and protracted symptoms of BPPV include surgical procedures such as transection of the posterior ampullary nerve or fenestration and occlusion of the posterior semicircular canal [Fife et al, 2008; DTB, 2009].

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