GMJ.

2019;8:e866
www.gmj.ir

Received 2017-04-16
Revised 2017-09-24
Accepted 2017-10-01

Comparing the Effects of Epley Maneuver and

Cinnarizine on Benign Positional Paroxysmal
Vertigo; A Randomized Clinical Trial
Masoumeh Saeedi1, Mohammad Hossein Khosravi2,3, Mohammad Ehsan Bayatpoor2

1
Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Baqiyatallah University of Medical Sciences,
Tehran, Iran
2
Student Research Committee, Baqiyatallah University of medical sciences, Tehran, Iran
3
International Otorhinolaryngology Research Association (IORA), Universal Scientific Education and Research Network (USERN),
Tehran, Iran

Abstract

Background: The fastest and safest treatment method of BPPV is repositioning maneuvers. In
Iran, this methods are not widely used, and many physicians use medical therapy, despite their
side effects, for management of BPPV. Materials and Methods: In this randomized clinical tri-
al patients with BPPV were randomly allocated to Epley repositioning maneuver or Cinnarizine
(25mg every 8 hours) for two weeks. The patients were evaluated for symptoms using visual
analogue scale (VAS) scoring system before intervention, first and second weeks after inter-
vention. In the second and third visitd the results of hallpike test was recorded for both groups.
Results: 43 patients with a mean age of 46.88±11.08 years in two Epley and Cinnarizine group
underwent analysis. The mean VAS score for improvement of symptoms after intervention was
1.66±1.06 in Epley and 1.50±0.91 in Cinnarizine group (P=0.57). Conclusion: we found that
there is no significant difference between Epley maneuver and Cinnarizine for treatment and
controlling symptoms of BPPV. [GMJ.2019;8:e866] DOI:10.31661/gmj.v8i0.866

Keywords: Benign Paroxysmal Positional Vertigo; Cinnarizine; Epley Maneuver; Vertigo

Introduction mon site of involvement; however horizontal

and superior canals are rarely affected [1].

B enign positional paroxysmal vertigo

(BPPV) is one of the most important
causes of vertigo with a prevalence of 11-64
BPPV is routinely managed by drugs such as
Cinnarizine, an histamine antagonist and cal-
cium channel blocker, which improves verti-
per 100000 people and a life- long preva- go through effecting on calcium channels in
lence of 2.4% [1]. It is considered that BPPV peripheral vestibular labyrinth [5, 6]. Repo-
symptoms occur when otoconia are dislodged sitioning maneuvers are the fastest and safest
from otolith structures and attached to cupu- non-surgical practical treatment of BPPV that
la in semicircular canals [2-4]. It is believed are performed by changing head and body po-
that posterior semicircular canal is the com- sitions. These treatments are completely avail-

GMJ 
Correspondence to:
Mohammad Hossein Khosravi, Student Research Com-
Copyright© 2019, Galen Medical Journal. This is mittee, Baqiyatallah University of Medical Sciences,
an open-access article distributed under the terms of
the Creative Commons Attribution 4.0 International Mollasadra st., Vanaq sq., Tehran, Iran
License (http://creativecommons.org/licenses/by/4.0/) Telephone Number: +982188620826
Email:[email protected]
Email Address: [email protected]
 Saeedi M, et al. Epley Maneuver vs. Cinnarizine in BPPV

able and take only 5 minutes [7]. Epley, a spe- tients were recommended to place their head
cific maneuver for posterior semicircular canal 45 degrees upper the body level during sleep
BPPV with a high rate of success (85-90%), for two days. The patients were evaluated for
is one of these maneuvers which has no sever symptoms using visual analogue scale (VAS)
complications except nausea and vomiting [8- scoring system before intervention, first and
11]. According to previous studies, improve- second weeks after intervention. In the second
ment rate of symptoms ranges between 50 to and third visit, Epley maneuver was repeated
95% one to two weeks after treatment [12-14]. in group A patients and the results of hallpike
Applying this therapeutic method is not com- test was recorded for both groups. Data were
mon in Iran and most of physicians prescribe analyzed using SPSS software version 21
medications for patients with vertigo. Accord- (SPSS Inc., Chicago, IL) for Microsoft Win-
ing to this issue and that few studies have been dows. Sample size was calculated using
yet conducted to compare these two methods, “N= 2(Z 1-α + Z 1-β) 2 * P(1-P) / ( P0-P1) 2 “
we aimed to compare the effectiveness of Ep- formula. The chi square test was used to com-
ley maneuver and Cinnarizine in treatment of pare categorical variables in the 2 groups. In-
BPPV. dependent sample t test and its nonparametric
equivalent were used to compare the values
Materials and methods before and after treatment within the groups.
A P value of less than 0.05 was considered as
This randomized clinical trial was regis- statistically significant.
tered at ethics committee of Baqiyatallah
University of Medical Sciences (Reference Results
no: IR.BMSU.REC.1391.112) and Iranian
Registry of Clinical Trials (Reference no: Eventually 43 patients (25 male and 18 fe-
IRCT2016101717413N19). Figure-1 shows male) with a mean age of 46.88±11.08 years in
a flowchart of the trial. Patients with Benign two Epley (48.19±9.82) and Cinnarizine group
Positional Paroxysmal Vertigo (BPPV) attend- (45.63±12.26) underwent analysis (P=0.457).
ing to vertigo clinic of Baqiyatallah hospital, Epley and Cinnarizine groups consisted 13 and
Tehran, Iran in 2014 and 2015 were assessed 12 male patients, respectively (P=0.42). In Ep-
for eligibility. All patients were informed ley group 17 (80%) patients and in Cinnarizine
of study process and possible side effects. A group 9 (40%) patients complained of dis-
written informed consent was obtained from equilibrium (P=0.012). Eight (38%) patients
all of patients. Patients with definite diagno- in Epley group and 6 (27%) patients in Cin-
sis of BPPV, up to 2 days after diagnosis, and narizine group had head-lightness (P=0.44).
those who have not received any treatments Most of patients in Epley (76%) and Cin-
for BPPV were included. BPPV diagnosis was narizine (86%) groups had nausea (P=0.232);
made by single physician based on history tak- while 6(28%) patients in Epley group and 2
ing and hallpike test. Patients with no definite (9%) patients in Cinnarizine group had vomit-
diagnosis and those suspicious for other caus- ing during vertigo (P=0.175). In Epley group
es of vertigo, especially CNS involvement, 7(33%) and in Cinnarizine group 3 (13%)
were excluded from the study. Patients were patients mentioned sweating during vertigo
randomized to two groups using random num- (P=0.062). Symptoms were present for less
ber table: the first group (A) underwent Epley than one month in 12(57%), one month to
repositioning maneuver by single physician one year in 8(38%) and more than one year in
and the second group (B) used Cinnarizine 1(4%) patients in Epley group. In Cinnarizine
(25mg every 8 hours) for two weeks. The group 9(40%), 10(45%) and 3(14%) patients
block randomization was accomplished by had symptoms for less than month, one month
the clinic’s automatic turn system and patients to one year and more than one year, respec-
were randomized into 2 groups at a ratio of 1:1 tively (P=0.433). Changing position was
and a block size of 4. In the first visit, results mentioned as provoking agent by 14(66%)
of hallpike test was recorded for both groups patients in Epley and 10(45%) patients in Cin-
and after first Epley maneuver, group A pa- narizine group. Valsalva maneuver worsened

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Epley Maneuver vs. Cinnarizine in BPPV Saeedi M, et al.

Figure 1. Study flowchart

symptoms in 4(18%) patients in Cinnarizine cally significant relation between mean VAS
group. In 7(33%) patients in Epley group and score (1.58±0.981) and mean age of patients
8(36%) in Cinnarizine group symptoms were based on Pearson Correlation (P=0.449). The
worsened spontaneously (P=0.095). Four mean VAS score of female patients was 1 unit
patients (19%) in Epley and 8(36%) in Cin- more than male patients (P=0.001, Table-3).
narizine group had a history of head trauma Patients with longer disease duration, spon-
(P=0.206). In Epley group 9(42.9%) patients taneous exacerbation of symptoms, all three
and in Cinnarizine group 14(63.6%) patients ototonic symptoms (sweating, nausea and
had a positive history for other ear diseases vomiting), no history of head trauma or oth-
(P=0.172). Table-1 summarizes other com- er inner ear disease and those without otalgia
plaints of patients prior to intervention. The had a significantly higher VAS score (p<0.05,
mean VAS score for improvement of symp- Table-3). Mean VAS score was not significant-
toms after intervention was 1.66±1.06 in Epley ly different between patients with or without
and 1.50±0.91 in Cinnarizine group (p=0.57). hearing loss (P=0.336).
Table-2 shows improvement of symptoms re-
ported by patients. In Epley group 3(14%) pa- Discussion
tients and 1(4%) in Cinnarizine group report-
ed “complete resolution of symptoms”. While We found that there is no significant difference
1(4.8%) patient in Epley and 1(4.5%) patient between Epley maneuver (A) and Cinnarizine
in Cinnarizine group reported “no changes” (B) for management of symptoms in patients
in symptoms (P=0.34). There was no statisti- with BPPV. All demographic characteristics

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 Saeedi M, et al. Epley Maneuver vs. Cinnarizine in BPPV

and symptoms except disequilibrium were ararajan et al. study patients underwent one
not significantly different between two groups week of treatment and were followed for four
before intervention. Also there was no statis- weeks. The results are in concordance with the
tically significant difference between A and B present study in effect of Epley maneuver on
groups for mean VAS score. Female patients eliminating symptoms of patients. In contrast
and those with longer disease duration, spon- with the present study, they concluded that
taneous exacerbation of symptoms and all labyrinth sedatives were not effective which
three ototonic symptoms (sweating, nausea may be a result of different study designs [18].
and vomiting) had a significantly higher VAS Evaluating the effect of Epley maneuver, with
score in both groups. While this was signifi- and without Betahistine, on the treatment of
cantly lower in patients with history of head BPPV, Guneri et al. concluded that medical
trauma or other inner ear disease and otalgia. treatment is effective as well as repositioning
Our findings confirm the results of Cohen et maneuver which is in agreement with the pres-
al. study for effect of Epley maneuver with ent study [19]. In accordance with the present
sleep position recommendations in controlling study, Foster et al. confirmed the effect of Ep-
symptoms of patients with BPPV and also ley maneuver on the treatment of BPPV. They
Steenerson et al. study for effect of reposition- have also presented “Half somersault” exer-
ing maneuvers on the treatment of BPPV [15, cise as a more resistant maneuver than Epley
16]. The present study has considered lim- with less complications. The six-month follow
itations mentioned in Helminski et al. study up time has made their study distinguished
and assessed confounders like history of head [20]. Maslovara et al. study is in agreement
trauma and other inner ear disease in the pa- with the present study for the effect of Epley
tients [17]. Sundararajan et al. evaluated the maneuver on BPPV. They have mentioned
adjunctive effect of labyrinth sedatives to Ep- neck brace, neck movement limitation and
ley maneuver on the treatment of BPPV; while upright sleep position associated with Epley
we compared medical treatment with Epley maneuver are accompanied with less relapses
maneuver in two groups of patients. In Sund- than Epley maneuver alone. Maslovara et al.

Table 1.Other Complaints of Patients Prior to Intervention

Epley maneuver Cinnarizine Total
P-value*
N=21 N=22 N=43
Age (Mean±SD) 48.19±9.82 45.63±12.26 46.88±11.08 0.45
Otalgia 2(9.5%) 4(18.2%) 6(14%) 0.66
Tinnitus 12(57.1%) 13(59.1%) 25(58.1%) 0.89
Increased
9(42.8%) 13(59.1%) 22(51.1%) 0.42
Discharge
Hearing loss 9(42.8%) 8(36.4%) 17(39.5%) 0.63

Table 2. Changes of Symptoms Reported by Patients

Complete Significantly Slightly
Improved No change
Resolution Improved Improved
Epley group
3(14.3%) 6(28.6%) 8(38.1%) 3(14.3%) 1(4.8%)
N=21
Cinnarizine group
1(4.5%) 13(59.1%) 5(22.7%) 2(9.1%) 1(4.5%)
N=22
Total
4(9.3%) 19(44.2%) 13(30.2%) 5(11.6%) 2(4.7%)
N=43
P-value 0.34

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Epley Maneuver vs. Cinnarizine in BPPV Saeedi M, et al.

Table 3. Relation between Mean VAS Score and Patients Characteristics after Intervention
Mean VAS
P-value
score (±SD)
Gender Male 1.16±0.62 0.001
Female 2.16±1.09
Disease duration <1 month 0.95±0.58
>1month, <1 year 1.88±0.67 0.001
> 1 year 3.5±0.57
Provoking agent Changing position 1.04±0.62
Valsalva maneuver 1 0.001
Spontaneous 2.60±0.73
Ototonic symptoms Nausea (N=27) 1±0.55
Sweating (N=8) 2.25±0.46 0.001
Nausea and Vomiting (N=6) 2.83±0.75
Sweat and Nausea and Vomiting (N=2) 3±1.41
History of Head Trauma Yes (N=12) 0.66±0.49 0.01
No (N=31) 1.93±0.89
History of inner ear disease Yes (N=23) 0.82±0.38 0.02
No (N=20) 2.04±0.68
Otalgia Yes (N=6) 0.66±0.51 0.012
No (N=37) 1.72±0.96
Hearing loss Yes (N=17) 1.41±0.71 0.336
No (N=26) 1.69±1.12

have also reported notable effects of Mastoid for patients who cannot tolerate repositioning
vibration techniques [21]. Kim et al. have re- maneuvers [25]. The present study had some
ported inner ear disease and hearing loss in the limitations. Blinding was not available in the
same side as factors related to treatment fail- present study because the two interventions
ure with Epley manuever which is in concor- were completely different. A relatively low
dance with our study [22]. In a similar study sample size is another limitation of the present
Sato et al. have mentioned head trauma as a study.
risk factor for BPPV treatment failure with
Epley maneuver; while inner ear diseases had Conclusion
not this condition [23]. Evaluating the effect
of Semont maneuver as an alternative meth- In conclusion we found that there is no sig-
od for repeating Epley maneuver, Oh et al. nificant difference between Epley maneuver
reported that there is no superiority for either and Cinnarizine for treatment and controlling
of the maneuvers in treatment of patients with symptoms of BPPV. So we suggest Epley ma-
posterior canal benign paroxysmal positional neuver for management of BPPV because of
vertigo [24]. In another study Kaur et al. eval- its lower expenses in comparison with med-
uated BPPV patients in three Epley maneuver ication. In addition this could be more effec-
alone, Betahistine alone and Betahistine plus tive in elderly patients, especially those with
Epley maneuver groups. They concluded that various prescribed medications, to decrease
concurrent prescription of Betahistine and the complications and quantity of drugs. Also
Epley maneuver is superior to other two op- further studies are suggested with more fol-
tions. They have also suggested Betahistine low up period and assessment of quality of
alone as an appropriate alternative treatment life of patients using standard questionnaires.

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 Saeedi M, et al. Epley Maneuver vs. Cinnarizine in BPPV

It is recommended that patients be evaluated Conflict of interest

in more groups for evaluating the effects of
different drugs, with or without repositioning There are no conflicts of interest in terms of
maneuvers. the present study.

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