The initial step in managing BPPV is patient education and reassurance.    If lateral (horizontal) canal or superior (anterior) canal BPPV variants are suspected, then referral to a tertiary care dizziness clinic is indicated. All patients with posterior canal BPPV should be offered a particle repositioning maneuver (PRM) unless there is a specific contraindication.    1[A] Evidence Evidence Repositioning maneuvers are simple to perform and can be easily mastered by family practice and emergency physicians.   Vestibular suppressant medications are not an effective treatment option.     2[B] Evidence Evidence
Explaining the non-life-threatening nature of BPPV and its favorable prognosis helps reassure patients that BPPV is not a serious condition. BPPV spontaneously remits in one third of patients at 3 weeks  and the majority of patients at 6 months from onset.  
It is highly treatable, with over 70% of episodes successfully treated after the administration of a single PRM.1[A] Evidence Evidence However, relapses and remissions can occur unpredictably in both treated and untreated patients.   Patients who have secondary BPPV (e.g., secondary to vestibular neuronitis) should be encouraged to return to normal physical activity to facilitate CNS compensation. 
The first-line treatment of posterior canal BPPV is a PRM, designed to clear the affected semicircular canal of debris. The repositioning maneuvers have a proven efficacy in the treatment of objective, subjective, secondary, and bilateral forms of posterior canal BPPV.    1[A] Evidence Evidence Contraindications to their use include severe cervical disease, unstable cardiovascular disease, suspected vertebrobasilar disease, and high-grade carotid stenosis. 
The goal of treating BPPV is to avoid many months of discomfort and the risk of accidents. Consequently, observation is not recommended in patients who are able to undergo a repositioning maneuver, given the maneuvers are simple, efficacious, and have a high benefit-to-risk ratio.  
In the US, the 3-position PRM is used most frequently. It involves the following steps:
Place the patient in a sitting position on the end of the examination table.
Rotate the head 45° toward the affected ear, then swiftly place the patient in a supine position with the head hanging 30° below the horizontal at the end of the examining table (Dix-Hallpike position).
Observe for primary stage nystagmus.
Maintain this position for 1 to 2 minutes.
The head is rotated 90° toward the opposite ear while maintaining the head hanging position.
Continue then to roll the whole patient (head and body) another 90° toward the unaffected side until their head is facing 180° from the original Dix-Hallpike position. This change in position should take <3 to 5 seconds.
The patient's eyes should be immediately observed for secondary-stage nystagmus. A favorable response occurs when the secondary-stage nystagmus is in the same direction as the primary-stage nystagmus, because the canalith particles would still be moving toward the utricle; an unfavorable response occurs when the nystagmus is in the opposite direction, which results when the particles regress away from the utricle toward its original position. Absence of nystagmus is not uncommon and may indicate mixed results, such as partial (incomplete) BPPV resolution.
Maintain the final position for 30 to 60 seconds, and then have the patient sit up. Upon sitting, there should be no vertigo or nystagmus in a successful maneuver because the particles will have been cleared from the posterior semicircular canal back into the utricle.
Particle-repositioning maneuver (right ear)
Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693. Used with permission
Trials have shown all of the repositioning maneuvers mentioned to be highly efficacious. The PRM is a variation of the Epley maneuver but is simpler and does not usually require sedation or mastoid vibration.   Although the PRM and Semont maneuvers share a similar mechanism and efficacy,      the PRM is used by most clinicians in North America because it is more comfortable for the patient and simpler to perform, especially in overweight and older patients.  The PRM has a well-documented short-term efficacy, with the majority of patients successfully treated after a single PRM attempt.    1[A] Evidence Evidence Postmaneuver instructions, including post-PRM postural restrictions, are not necessary.     4[A] Evidence Evidence Many studies have found no benefit; however, a Cochrane review found a statistically significant benefit,  although this may not be clinically significant.
Recently, a device for the home treatment of BPPV has been developed, which visually guides patients through the steps of the particle repositioning maneuver. 
Repositioning maneuvers have few adverse effects. An episode of BPPV is expected to occur during the therapeutic procedure. Occasionally, posterior BPPV can be converted to a lateral (horizontal) or anterior (superior) canal variant during a particle repositioning maneuver.  These patients need to be treated with the appropriate maneuvers for these variants or referred to a specialist dizziness clinic. Fortunately, the lateral canal variant has a very high spontaneous recovery rate. 
Emesis has been reported during repositioning maneuvers, particularly with the lateral canal variant,  and these patients may require antiemetic prophylaxis prior to initiating a subsequent repositioning maneuver.
Prolonged autonomic dysfunction and imbalance may occur in a small subset of patients, and vestibular suppressant medications may be beneficial in these cases.
There is a dichotomy where some experts practice only 1 PRM treatment per clinic visit, while others repeat the PRM until no nystagmus is observed on Dix-Hallpike testing.  The latter method is not recommended because an absent nystagmus response soon after a PRM may merely be the result of the Dix-Hallpike test's natural fatigability, as opposed to canalith clearance from the affected canal.  Moreover, there does not appear to be a difference in efficacy between single versus repeated PRM treatments per clinic visit with regard to short-term results and long-term relapses.   3[B] Evidence Evidence It is recommended that repeated PRM attempts during a clinic visit be reserved only for patients with an unfavorable nystagmus response, such as a nonipsidirectional nystagmus (reversed or absent nystagmus) at the second stage of a 3-position PRM, or a reversed nystagmus in the sitting position at the conclusion of a 3-position PRM.  An unfavorable nystagmus response has been documented to be a poor predictor of success.   However, it may take more than 1 clinic visit or session to successfully treat BPPV. The literature shows that multiple sessions of the PRM are more efficacious than a single session.  
If there is no sign of nystagmus and no symptoms of vertigo on Dix-Hallpike testing at follow-up, then the BPPV episode has resolved. All patients should undergo follow-up 1 to 4 weeks after treatment.  The treated side should be retested first with the Dix-Hallpike maneuver. If it remains positive, another PRM should be attempted or a referral to a specialist clinic dealing in dizziness should be considered. If the Dix-Hallpike maneuver is negative on the treated side at follow-up, the Dix-Hallpike should be performed on the untreated side and if positive, a PRM should be carried out on this side.
If the PRM fails after repeat office visits, then timely referral to a tertiary care centre dizziness clinic is indicated.  However, depending on the physician's experience and familiarity with BPPV and its management, other repositioning maneuvers may be attempted prior to referral. The Semont (liberatory) maneuver shares a similar mechanism and efficacy to the PRM and is the next option.      5[B] Evidence Evidence
Liberatory maneuver of Semont (right ear)
Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693. Used with permission
The Semont (liberatory) maneuver is thought to be useful for the treatment of both canalithiasis and cupulolithiasis forms of posterior canal BPPV.  The maneuver involves the following steps:
Sit the patient on an examination table, midway along the long side, with their legs hanging over the edge of the table.
Rotate the head 45° toward the unaffected side. While maintaining the head rotation, swiftly place the patient's upper body in a side-lying position on their affected side, with the head resting on the examination table and now facing upward. This may induce nystagmus and vertigo because of particle movement toward the apex of the semicircular canal. Maintain this position until the vertigo and nystagmus stop (1 to 2 minutes).
Move the patient rapidly through the sitting position of step 1 and into the opposite side-lying position while maintaining the same head rotation, so that the head is resting on the examination table and now facing downward. A nystagmus response in the same direction would indicate that the particles are exiting the semicircular canal. The transition from step 2 to 3 relies on inertia, and therefore it must be done very quickly. Maintain this position until the vertigo and nystagmus stop (1 to 2 minutes). Then slowly return the patient to the sitting position of step 1.
If both the PRM and the Semont (liberatory) maneuvers fail after repeat office visits, then referral to a specialist or tertiary care clinic dealing in dizziness is indicated. 
Contraindications to the use of repositioning maneuvers include severe cervical disease, unstable cardiovascular disease, suspected vertebrobasilar disease, and high-grade carotid stenosis.  If repositioning maneuvers fail after repeat office visits, then prompt referral to a tertiary specialist dizziness clinic is indicated.  Depending on the physician's experience and familiarity with BPPV and its management, other treatment options can be attempted prior to referral. Vestibular rehabilitation exercises such as the Brandt-Daroff are the next option and have shown some efficacy in the literature, although this appears to be less effective than the PRM and the Semont (liberatory) maneuver.       6[B] Evidence Evidence
The Brandt-Daroff exercises are done as follows:
Sit on the edge of a bed or sofa. The patient then quickly leans sideways to the side that causes the worst vertigo, until they end up lying on their side with their ear down against the bed or sofa.
The patient remains in this position until either the vertigo resolves or 30 seconds elapse.
The patient then returns to the original vertical sitting position. If this causes vertigo, the patient waits for it to stop. The procedure is then repeated on the other side.
Patients are usually instructed to do 20 repetitions of the exercise at least twice a day.
Patients with contraindications to or unable to tolerate repositioning maneuvers may benefit from vestibular rehabilitation therapy under the supervision of a physical therapist.  Modified Brandt-Daroff exercises or specific vestibular habituation exercises are also available. For patients with cervical spine or other issues that limit neck extension, a 30° bed tilt during the PRM can avoid the need for neck extension.
The PRM is much less arduous for the patient than home exercise regimens such as the Brandt-Daroff, which require daily self-administration and long-term patient compliance.  It should be noted that the PRM and Semont (liberatory) maneuvers treat the underlying mechanism of posterior canal BPPV by clearing the debris from the affected posterior semicircular canal. Brandt-Daroff exercises, although initially designed to produce central compensation, are quite similar to the Semont maneuver and so probably inadvertently work in the same way.
The use of vestibular rehabilitation to prevent recurrences in BPPV is unclear. Vestibular rehabilitation for an episodic condition such as BPPV has no physiologic basis: improvement may result from either a placebo effect or the rehabilitation of an associated vestibulopathy that resulted in the BPPV.
For patients with cervical spine or other issues that limit neck extension, there is a special chair called the Epley Omniax that can spin and position patients in any plane in space without the need for neck movements.  8[C] Evidence Evidence Most patients will not require such sophisticated technology and can make do with a simple tilting bed. By performing the PRM with the bed tilted back 30°, neck extension can be avoided. It should be noted that a 30° tilt is greater than one might imagine, and caution is needed as patients will have a tendency to slide down the tilting bed. Thus, although most PRMs can be easily carried by a solo clinician, a PRM with a 30° bed tilt will require at least 1 assistant.
Subjective BPPV occurs when the Dix-Hallpike maneuver or supine lateral head roll induces the typical vertigo with latency and limited duration, but without any objective nystagmus. This subset of patients is also highly responsive to repositioning maneuvers.   9[B] Evidence Evidence
Repositioning maneuvers are efficacious in both primary and secondary causes of BPPV.   10[C] Evidence Evidence Post-traumatic causes of BPPV are also highly amenable to treatment via the PRM, although it is more difficult to treat and has greater recurrences compared with nontraumatic forms.  11[C] Evidence Evidence Simultaneous bilateral BPPV is usually the result of a closed-head injury.  This phenomenon is diagnosed when patients are Dix-Hallpike positive on both sides simultaneously, and this condition is also amenable to repositioning maneuvers.  13[C] Evidence Evidence The side with the stronger vertigo and nystagmus response should be treated at the initial visit, whereas the other side is left alone to avoid re-displacing the canalith particles back into the contralateral (original) posterior canal. 
The vast majority of BPPV cases will respond to repositioning maneuvers or resolve spontaneously. The surgical treatment of BPPV is reserved for unrelenting cases in which severe symptoms and incapacity remains despite repeated attempts with repositioning maneuvers and vestibular rehabilitation exercises.   Surgical treatment may also be considered for patients who respond to PRMs but have unremitting recurrences soon after, to the extent that they are eager for a definitive solution rather than repeated PRMs. Less than 1% of BPPV patients will ever require surgery,  but because BPPV is so prevalent the actual number of surgical candidates is not negligible. Prior to undergoing surgery, all other potential diagnoses must be excluded and the posterior fossa imaged.
There are 2 surgical procedures for BPPV: singular neurectomy and posterior canal occlusion. The recommended surgical procedure is posterior canal occlusion, as this has been shown to be a highly efficacious, safe, and reproducible technique in numerous studies.            12[A] Evidence Evidence The premise is that obstruction of the posterior semicircular canal lumen prevents endolymphatic flow and thus renders the cupula immobile.
Outcomes are excellent. One systematic review found 94 of 97 ears treated were completely cured, with only 4 cases of hearing loss.  Studies that used the validated dizziness handicap inventory (DHI) questionnaire found DHI scores of 18.05 and 38.5 in BPPV patients before a PRM treatment,   whereas preoperative patients with intractable BPPV had DHI scores of 70.  Hence, many experts consider intractable BPPV a nonbenign condition, in contradistinction to what the name would suggest.  The most recent study involved 28 patients who had undergone posterior canal occlusion surgery with a mean follow-up of 40 months; it found all patients had a negative Dix-Hallpike test post-surgery, 95% improved significantly on the DHI questionnaire from an average score of 70 preoperatively to 13 postoperatively, and 85% were satisfied with their postoperative experience. 
Recurrences are common after successful treatment with repositioning maneuvers, as high as 50% after 40 months post-treatment,  and further repositioning maneuvers are indicated in these circumstances. Meniere disease (endolymphatic hydrops), CNS diseases, migraine headaches, and post-traumatic BPPV have all been associated with a greater risk of recurrence.     Thus, all factors suggest that a long-term recurrence of BPPV is not due to a recalcitrant condition, but instead results from a new episode of the underlying condition that caused BPPV the first time around. Persistent recurrences despite adequate treatment are an indication for referral to a tertiary specialist dizziness clinic. Some patients can be taught how to do repositioning maneuvers at home on an intermittent basis when their symptoms recur. The DizzyFIX, which is a new device for the home treatment of BPPV, may be particularly useful for treating recurrent cases of BPPV. 
Referral to a tertiary specialist dizziness clinic is indicated in the following situations: 
Multiple recurrences despite adequate treatment
Suspected lateral (horizontal) canal and the rare superior (anterior) canal BPPV variants
Atypical cases (symptoms of hearing loss, tinnitus, pressure sensations or aural fullness, symptoms triggered by ear or intracranial pressure changes, signs of middle ear infection, odd nystagmus profiles during positioning maneuvers, persistent dizziness or unsteadiness)
Patients with other neurologic symptoms and signs that may require imaging of the posterior fossa.