Benign Paroxysmal Positional Vertigo

Publication Date: March 1, 2017
Last Updated: December 16, 2022

Table 2. Summary of Key Action Statements (KAS)

Diagnosis of posterior canal BPPV

Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, up-beating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45º to one side and neck extended 20º with the affected ear down. The maneuver should be repeated with the opposite ear down if the initial maneuver is negative. ( Strong Recommendation (S) , B )

Diagnosis of lateral (horizontal) canal BPPV

If the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus, the clinician should perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV. ( Recommendation (R) , B )

Differential diagnosis

Clinicians should differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo. ( Recommendation (R) , C )

Modifying factors

Clinicians should assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling. ( Recommendation (R) , C )

Radiographic testing

Clinicians should NOT obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging. ( Recommendation (R) , C )

Vestibular testing

Clinicians should NOT order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing. ( Recommendation (R) , C )

Repositioning procedures as initial therapy

Clinicians should treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. ( Strong Recommendation (S) , A )

Postprocedural restrictions

Clinicians should NOT recommend postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. ( Strong Recommendation (S) , A )

Observation as initial therapy

Clinicians may offer observation with follow-up as initial management for patients with BPPV. ( Option (O) , B )

Vestibular rehabilitation therapy

The clinician may offer vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV. ( Option (O) , B )

Medical therapy

Clinicians should NOT routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. ( Recommendation (R) , C )

Outcome Assessment

Clinicians should reassess patients within one month after an initial period of observation or treatment to document resolution or persistence of symptoms. ( Recommendation (R) , C )

Evaluation of treatment failure

Clinicians should evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders. ( Recommendation (R) , A )


Clinicians should educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence and the importance of follow-up. ( Recommendation (R) , C )

Recommendation Grading




Benign Paroxysmal Positional Vertigo

Authoring Organization

Endorsing Organizations

Publication Month/Year

March 1, 2017

Last Updated Month/Year

July 26, 2023

Document Type


External Publication Status


Country of Publication


Document Objectives

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers.

Target Patient Population

Aged ≥18 years with a suspected or potential diagnosis of BPPV

Target Provider Population

All clinicians who are likely to diagnose and manage patients with BPPV

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Long term care

Intended Users

Audiologist, nurse, nurse practitioner, physician, physician assistant


Diagnosis, Management

Diseases/Conditions (MeSH)

D065635 - Benign Paroxysmal Positional Vertigo


benign paroxysmal positional vertigo (BPPV), BPPV, vertigo

Source Citation

Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery. 2017;156(3_suppl):S1-S47. doi:10.1177/0194599816689667

Supplemental Methodology Resources

Data Supplement


Number of Source Documents
Literature Search Start Date
January 1, 2008
Literature Search End Date
September 1, 2015