The evidence grades (A-D, X) and evidence-based statements (Strong Recommendation, Recommendation, Option, and No Recommendation) are defined at the end of the "Major Recommendations" field.
Statement 1a. Diagnosis of Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV)
Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45 degrees to one side and neck extended 20 degrees.
Strong recommendation based on diagnostic studies with minor limitations and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade B, based on diagnostic studies with minor limitations
- Benefit: improved diagnostic accuracy and efficiency
- Harm: risk of provoking temporary symptoms of BPPV
- Cost: minimal
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: conclusion that paroxysmal positional nystagmus induced by the Dix-Hallpike maneuver confirms the diagnosis of BPPV and is the gold standard test for diagnosis (The panel emphasized that a history of positional vertigo alone should not be relied upon for the diagnosis of posterior canal BPPV.)
- Role of patient preferences: minimal
- Patient exclusions: patients with physical limitations including cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, ankylosing spondylitis, low back dysfunction, spinal cord injuries, and morbid obesity
- Policy level: strong recommendation
Statement 1b. Diagnosis of Lateral Canal BPPV
If the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, the clinician should perform a supine roll test to assess for lateral semicircular canal BPPV.
Recommendation based on diagnostic studies with limitations and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on observational studies with limitations and selected populations
- Benefit: avoidance of a false-negative result in the diagnosis of BPPV attributable to a missed lateral canal variant; allowance of confirmation of a diagnosis of lateral canal BPPV, thereby avoiding unnecessary diagnostic tests
- Harm: risk of provoking temporary symptoms of BPPV
- Cost: minimal
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: the importance of evaluating additional variants of BPPV rather than limiting the evaluation to posterior canal BPPV
- Role of patient preferences: minimal
- Exclusions: patients with physical limitations including cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, morbid obesity, ankylosing spondylitis, low back dysfunction, and spinal cord injuries
- Policy level: recommendation
Statement 2a. Differential Diagnosis of BPPV
Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo.
Recommendation based on observational studies and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on observational studies with limitations
- Benefit: prevention of false-positive diagnosis of BPPV when another condition actually exists
- Harm: none
- Cost: minimal
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: none
- Role of patient preferences: minimal
- Policy level: recommendation
Statement 2b. Modifying Factors
Clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, central nervous system (CNS) disorders, a lack of home support, and increased risk for falling.
Recommendation based on observational and cross-sectional studies and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on observational and cross-sectional studies
- Benefit: allowance for global management of patients with BPPV with appropriately structured comprehensive treatment plan; identification of patients at risk for falls and prevention of fall-related injury
- Harm: none
- Cost: none
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: the management of BPPV will benefit from assessment of these modifying factors
- Role of patient preferences: minimal
- Policy level: recommendation
Statement 3a. Radiographic and Vestibular Testing
Clinicians should not obtain radiographic imaging, vestibular testing, or either in a patient diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing.
Recommendation against based on diagnostic studies with limitations and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on diagnostic studies with limitations in referred patient populations and observational studies for vestibular testing; Grade C, based on observational studies for radiographic imaging
- Benefit: facilitation of prompt treatment by avoiding unnecessary testing associated with low yield and potential false-positive diagnoses; avoidance of radiation exposure and adverse reactions to testing
- Harm: potential missed diagnosis of comorbid conditions; discomfort such as nausea and vomiting produced by vestibular testing
- cost savings associated with decreased testing
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: importance of reducing unnecessary testing and delays in diagnosis
- Role of patient preferences: minimal
- Exclusions: patients who have separate indications for radiographic or vestibular testing aside from confirmation of a diagnosis of BPPV
- Policy level: recommendation against
Statement 3b. Audiometric Testing
No recommendation is made concerning audiometric testing in patients diagnosed with BPPV.
No recommendation based on insufficient evidence for the diagnostic or prognostic value of audiometry in the evaluation of BPPV.
Evidence Profile:
- Aggregate evidence quality: Grade D, based on expert opinion specifically in the BPPV population and an absence of diagnostic studies on audiometry in BPPV
- Benefit: possible identification of an unsuspected hearing loss or an underlying otological condition
- Harm: delay in treatment if audiometry is not readily available
- Cost: possible realization of cost savings if fewer audiograms are performed
- Benefit-harm assessment: relative balance of benefit and harm
- Value judgments: Ease of identification of a small subset of patients in whom audiometry might be valuable on the basis of the clinical history
- Role of patient preferences: minimal
- Policy level: no recommendation
Statement 4a. Repositioning Maneuvers as Initial Therapy
Clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver.
Recommendation based on randomized controlled trials with small sample sizes and heterogeneity conducted in specialty practice settings and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade B, based on randomized controlled trials (RCTs) with small sample sizes and significant heterogeneity (Most studies were conducted in specialty practice settings with limited data from other treatment settings, potentially limiting generalizability of results).
- Benefit: prompt resolution of symptoms with a relatively low number needed to treat (NNT) ranging from 1 to 3
- Harm: transient provocation of symptoms of BPPV by the maneuver; risk for falls due to imbalance after the procedure; no serious adverse events reported in RCTs
- Cost: cost of the procedure
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: high value ascribed to prompt resolution of symptoms and the ease with which the canalith repositioning procedure (CRP) may be performed
- Role of patient preferences: limited
- Exclusions: patients with physical limitations including cervical stenosis, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, morbid obesity, ankylosing spondylitis, low back dysfunction, retinal detachment, and spinal cord injuries may not be candidates for this maneuver or may need specialized examination tables for performance of the maneuver
- Policy level: recommendation
Statement 4b. Vestibular Rehabilitation as Initial Therapy
The clinician may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV.
Option based on controlled observational studies and a balance of benefit and harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on controlled observational studies and limited randomized controlled trials
- Benefit: potentially faster resolution of symptoms compared with observation alone
- Harm: no serious adverse events noted in published trials; transient provocation of BPPV symptoms during rehabilitation exercises; potential for delayed symptom resolution compared with PRMs as a sole intervention
- Cost: need for repeated visits if done with clinician supervision; cost of therapy
- Benefit-harm assessment: relative balance of benefits and harm
- Value judgments: vestibular rehabilitation considered possibly better as an adjunctive therapy rather than a primary treatment modality. (Subsets of patients with preexisting balance deficit, central nervous system disorders, or risk for falls may derive more benefit from vestibular rehabilitation than the patient with isolated BPPV.)
- Role of patient preferences: substantial role for shared decision making
- Exclusions: patients with physical limitations such as cervical stenosis, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, morbid obesity, ankylosing spondylitis, low back dysfunction, and spinal cord injuries
- Policy level: option
Statement 4c. Observation as Initial Therapy
Clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up.
Option based on data from cohort and observational studies with heterogeneity and a relative balance of benefits and harms.
Evidence Profile:
- Aggregate evidence quality: Grade B, based on control groups from randomized controlled trials and observational studies with heterogeneity in follow-up and outcomes measures
- Benefit: symptom resolution in 15 to 85 percent of patients at 1 month without intervention
- Harm: prolonged symptoms compared with other interventions that may expose patients to increased risks for falls or lost days of work
- Cost: indirect costs of delayed resolution compared with other measures
- Benefit-harm assessment: relative balance of benefits and harms
- Value judgments: bias of the panel for treatment intervention rather than observation, particularly with respect to the value of a quicker time to resolution (The panel felt that older patients and patients with preexisting balance disorders or high risks for falls may not be suitable for observation.)
- Role of patient preferences: substantial for shared decision making
- Exclusions: none
- Policy level: option
Statement 5. Medical Therapy
Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines.
Recommendation against based on observational studies and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on observational and cross-sectional studies
- Benefit: unknown or unclear benefit in patients with BPPV
- Harm: adverse effects from or medication interactions with these medications; decreased diagnostic sensitivity during Dix-Hallpike maneuvers from vestibular suppression
- Cost: none
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: avoidance of harm from ineffective treatments
- Role of patient preferences: minimal
- Exclusions: severely symptomatic patients refusing other treatment options and patients requiring prophylaxis for canalith repositioning procedure
- Policy level: recommendation against
Statement 6a. Reassessment of Treatment Response
Clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution.
Recommendation based on observational outcomes studies and expert opinion and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on studies with known significant failure rates for an observation option and lower failure rates for particle repositioning maneuver (PRM)
- Benefit: increased accuracy of diagnosis of BPPV; identification of patients with persistent symptoms who were initially treated with observation and may benefit from vestibular rehabilitation or PRM to hasten symptom resolution
- Harm: none
- Cost: cost of reassessment
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: assurance of accuracy of diagnosis and capture of patients who could benefit from treatment or re-treatment to improve symptom resolution
- Role of patient preferences: minimal
- Policy level: recommendation
Statement 6b. Evaluation of Treatment Failure
Clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders.
Recommendation based on observational studies of diagnostic outcomes in patients with BPPV and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on case series of treatment failure and limited retrospective diagnostic studies
- Benefit: expedition of effective treatment of patients with persistent BPPV and associated comorbidities; decrease in the potential for missed serious medical conditions that require a different treatment algorithm
- Harm: none
- Cost: costs of reevaluation and the additional testing
- Benefit-harm assessment: preponderance of benefit vs. harm
- Value judgments: comprehensive treatment of not only BPPV but associated conditions that affect balance and function; expeditious treatment of cases of persistent BPPV with a particle repositioning maneuver (as more definitive therapy) following the failure of observation or vestibular rehabilitation
- Role of patient preferences: minimal
- Policy level: recommendation
Statement 7. Education
Clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.
Recommendation based on observational studies of diagnostic outcomes and recurrence in patients with BPPV and a preponderance of benefit over harm.
Evidence Profile:
- Aggregate evidence quality: Grade C, based on observational and cross-sectional studies of recurrence and fall risk
- Benefit: increased awareness of fall risk, potentially decreasing injuries related to falls; increased patient awareness of BPPV recurrence, allowing prompt intervention
- Harm: none
- Cost: none
- Benefit-harm assessment: preponderance of benefit over harm
- Value judgments: inadequate data to elaborate recommendations for patients with BPPV with regard to driving vehicles
- Role of patient preferences: none
- Policy level: recommendation
Definitions:
Guideline Definitions for Evidence-Based Statements
Strong Recommendation: A strong recommendation means the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation) and that the quality of the supporting evidence is excellent (Grade A or B). In some clearly identified circumstances, strong recommendations may be made on the basis of lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Implication: Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
Recommendation: A recommendation means the benefits exceed the harms (or that the harms exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (Grade B or C). In some clearly identified circumstances, recommendations may be made on the basis of lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. Implication: Clinicians should also generally follow a recommendation, but should remain alert to new information and sensitive to patient preferences.
Option: An option means that either the quality of evidence that exists is suspect (Grade D) or that well-done studies (Grade A, B, or C) show little clear advantage to one approach versus another. Implication: Clinicians should be flexible in their decision making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
No Recommendation: No recommendation means there is both a lack of pertinent evidence (Grade D) and an unclear balance between benefits and harms.
Implication: Clinicians should feel little constraint in their decision making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
Evidence Quality for Grades of Evidence
Grade A: Well-designed randomized controlled trials or diagnostic studies performed on a population similar to the guideline's target population
Grade B: Randomized controlled trials or diagnostic studies with minor limitations; overwhelmingly consistent evidence from observational studies
Grade C: Observational studies (case-control and cohort design)
Grade D: Expert opinion, case reports, reasoning from first principles (bench research or animal studies)
Grade X: Exceptional situations for which validating studies cannot be performed and there is a clear preponderance of benefit over harm