By Louise M. Klebanoff, MD
Synopsis: Benign positional vertigo is a challenge to treat. This clinical trial from investigators in South Korea demonstrated modest efficacy in resolving posterior canal-related vertigo with a head-shaking maneuver that is easily performed in an office setting.
Source: Oh EH, Choi JH, Kim HS, et al. Treatment maneuvers in cupulolithiasis of the posterior canal benign paroxysmal positional vertigo: A randomized clinical trial. JAMA Netw Open. 2025;8(3):e250972.
Benign paroxysmal positional vertigo (BPPV), which occurs when calcium carbonate crystals (otoconia) become dislodged from their usual position in the utricle and migrate into one of the semicircular canals, is one of the most common causes of vertigo, especially in the older patient population. BPPV can be classified as canalolithiasis when the otoconia are free-floating within the semicircular canal or cupulolithiasis when the otoconia are attached to the cupula. BPPV caused by cupulolithiasis of the posterior semicircular canal, as defined by The Bárány Society, produces positional nystagmus with the upper pole of the eye beating torsionally toward the lower ear and vertically upward, and lasting for more than one minute, which is longer than the BPPV caused by canalolithiasis.
Previous randomized trials have shown that head-shaking and mastoid oscillation maneuvers can effectively treat cupulolithiasis affecting the horizontal canal. The authors explored whether these maneuvers also could successfully treat cupulolithiasis of the posterior canal causing BPPV (PC-BPPV-cu).
The authors conducted a multicenter, randomized, double-blind clinical trial to assess the effectiveness of head-shaking and mastoid oscillation maneuvers in patients with PC-BPPV-cu. The diagnosis of PC-BPPV-cu was made based on the diagnostic criteria of the Classification Committee of Vestibular Disorders of The Bárány Society. Inclusion criteria were repetitive episodes of positional vertigo or dizziness; positional nystagmus beating torsionally with the upper pole of the eye to the lower ear and vertically upward and lasting for more than one minute, evoked by the Dix-Hallpike or half Dix-Hallpike maneuver; and absence of accompanying signs or symptoms of central nervous system dysfunction. Patients were randomly assigned to the head-shaking, mastoid oscillation, or control groups. Investigators assessing the outcomes and analysis were blinded to the patients’ information. Patients were not informed of the treatment they were receiving.
The head-shaking maneuver was performed with the patient sitting with their head pitched forward 30 degrees; the head then was moved laterally at a sinusoidal rate of approximately 3 Hz for 15 seconds. For the mastoid oscillation maneuver, the mastoid oscillation was applied to the area of the lesion side with 100-Hz handheld vibrator in a sitting position for 30 seconds. For the sham maneuver, the patients lay on the unaffected side and returned to the sitting position after one minute. Treatment response was assessed after 30 minutes. The absence of both vertigo and nystagmus was required to determine a resolution. Patients with persistent symptoms or signs had a repeat procedure. Patients then were assessed the following day. The primary endpoint was the short-term resolution rate of positional vertigo and nystagmus the following day.
The authors assessed 179 patients for eligibility, of whom 20 were excluded for a variety of reasons, leaving 159 patients for randomization into the head-shaking group (n = 53), mastoid oscillation (n = 53), or sham (n = 53). There was a higher proportion of women (67.9%) than men, the average age was 65.4 years, and the three groups were evenly matched in terms of demographics. A total of 142 patients (89.3%) completed the clinical assessment the following day.
In the intention-to-treat analysis, 20 patients in the head-shaking group (37.7%), 14 patients in the mastoid oscillation group (26.4%), and seven patients in the control group (13.2%) showed resolution of nystagmus and vertigo the day following the application of the maneuver. The head-shaking group had better therapeutic efficacy than the sham group. There were no significant differences in the therapeutic efficacy between the head-shaking group and mastoid oscillation group or between the mastoid oscillation group and sham group.
In the per-protocol analysis, 20 of 47 patients (42.6%) in the head-shaking group, 14 of 49 patients (28.6%) in the mastoid oscillation group, and seven of 46 patients (15.2%) in the control group showed resolution of vertigo and nystagmus the following day. The comparison of the therapeutic efficacy of the head-shaking group with the sham group was statistically significant; the other comparisons were not. In logistic regression analysis, the head-shaking group showed statistically higher odds of treatment success when compared with the mastoid oscillation or sham group.
Commentary
BPPV is one of the most common causes of peripherally mediated vertigo, caused by displacement of the otoliths in the inner ear. BPPV can involve any of the semicircular canals. BPPV caused by cupulolithiasis of the posterior canal can be challenging to treat. Through this randomized controlled trial, the authors showed that the head-shaking maneuver could effectively treat PC-BPPV-cu with a short-term success rate of 37.7% after two applications. Mastoid oscillation was not found to be more efficacious than the sham procedure.
This study provides possible treatment intervention for PC-BPPV-cu. The results are not particularly robust, with only a 37.7% short-term benefit. The long-term benefit is unknown. It also is uncertain if a different head position or a different rate of oscillation would be more effective. In clinical practice, determining the exact canal that is symptomatic, despite having established diagnostic criteria, can be challenging, which further limits the practical application of this maneuver. Nonetheless, this study provides additional treatment options for this common and functionally disabling condition. Additional clinical studies are warranted.
Louise M. Klebanoff, MD, is Assistant Professor of Clinical Neurology, Weill Cornell Medical College.
Benign positional vertigo is a challenge to treat. This clinical trial from investigators in South Korea demonstrated modest efficacy in resolving posterior canal-related vertigo with a head-shaking maneuver that is easily performed in an office setting.
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