The American Academy of Otolaryngology — Head and Neck Surgery foundation has released a clinical practice guideline for benign paroxysmal positional vertigo (BPPV).  The revised guideline, an update to the previous guideline issued in 2008, is published in Otolaryngology — Head and Neck Surgery.

The new recommendations emphasize diagnostic accuracy and efficiency, decreasing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing, and increasing the appropriate therapeutic repositioning maneuvers. The guideline incorporates new evidence from 2 clinical practice guidelines, 27 randomized controlled trials, and 20 systematic reviews.

A summary of the guidelines is as follows:

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  • Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver. The maneuver should be performed by bringing the patient from an upright position to a supine position with the head turned 45 degrees to the side and the neck extended 20 degrees with the affected ear down. If the initial maneuver is negative, the maneuver should be repeated with the opposite ear down.
  • Clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus.
  • Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo.
  • Clinicians should assess patients with BPPV for factors that modify management, such as impaired mobility or balance, central nervous system disorders, a lack of home support, and an increased risk for falling.
  • Clinicians should not obtain radiographic imaging in patients who meet diagnostic criteria for BPPV in the absence of additional signs or symptoms inconsistent with BPPV that warrant imaging.
  • Clinicians should avoid ordering vestibular testing in patients who meet diagnostic criteria for BPPV in the absence of additional vestibular symptoms inconsistent with BPPV that warrant testing.
  • Clinicians should treat patients with posterior canal BPPV with a canalith repositioning procedure.
  • Clinicians should not recommend postprocedural postural restrictions after a canalith repositioning procedure for posterior canal BPPV.
  • Clinicians may offer observation with follow-up as the initial management for patients with BPPV.
  • Clinicians may offer vestibular rehabilitation (self-administered or with a clinician) to treat BPPV.
  • Clinicians should not routinely treat BPPV with vestibular suppressant medications, such as antihistamines or benzodiazepines.
  • Clinicians should reassess patients within 1 month after the initial period of observation or treatment to document resolution or persistence of symptoms.
  • In patients with persistent symptoms, clinicians should evaluate for unresolved BPPV or underlying peripheral vestibular or central nervous system disorders.
  • Clinicians should educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.


  1. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: Benign paroxysmal positional vertigo (update) executive summary. Otolaryngol Head Neck Surg. 2017;156(3):403-416. doi:10.1177/0194599816689660