BPPV – Likelihood and Management of Recurrence

One disadvantage of being one of the few vestibular clinics in our area is that we typically have a backlog for new patient appointments. Sometimes we get a referral for a patient complaining of positional vertigo, but their symptoms have resolved by the time they get here. Since BPPV tends to recur, we feel like we can still be of help by making sure the patient doesn’t have any more worrisome issues that may be causing their symptoms. More importantly, we educate them about BPPV so that they can manage it more effectively in the future if they need to.

A critical aspect of effective management of BPPV is to counsel the patient as to the physiology and high likelihood of recurrence. A 2003 study reports that 37% of patients treated for BPPV will report a recurrence within 5 years. A 2012 study put that number at 27%, but noted that most recurrences occurred within 6 months of treatment. In other words, if you can go 6 months after repositioning without a recurrence, the chances of recurrence drop dramatically.

The patient should be educated regarding characteristics specific to BPPV, such as provoking positions, latency, and fatigue, so they can better self-direct care in the future. If they are comfortable that their symptoms are from BPPV, they may be able to avoid an expensive, and often unproductive, trip to the Emergency Room.

Some vestibular specialists advocate a short trial of home-based modified Epley procedures for suspected recurrence; however, this approach has been criticized as unnecessarily risky. Our approach is to counsel the patient to contact our clinic if they suspect a recurrence, and to avoid provocative head movement for several hours before arriving for examination to increase the likelihood of a positive Dix-Hallpike exam. If they have a recurrence in the same ear and same canal, and there are no contra-indicating factors, we may suggest they try a few days of the home Epley procedure before contacting us for future recurrences.

Many patients inquire as to any techniques that may prevent recurrence. Helminski et al. (2005) report that daily performance of Brandt-Daroff exercises did not result in a lower recurrence rate. We counsel our patients not to worry about it because they cannot prevent it. Other than never lying down, I don’t know of any way to prevent recurrences.

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.