Comparative efficacy and safety of repositioning maneuvers for posterior canal benign paroxysmal positional vertigo: a network meta-analysis

TL;DR

This study compares different repositioning maneuvers for treating BPPV and finds the Epley and Semont maneuvers to be most effective and safe.

Contribution

A network meta-analysis comparing the efficacy and safety of multiple repositioning maneuvers for posterior canal BPPV.

Findings

The Epley maneuver showed the highest overall effectiveness with a SUCRA of 97.84%.

Epley and Semont maneuvers had the best cure rates and favorable safety profiles.

No optimal strategy was identified for recurrence rate due to low evidence quality.

Abstract

This study aimed to systematically evaluate and compare the efficacy and safety of different repositioning maneuvers for posterior canal benign paroxysmal positional vertigo (BPPV).

PubMed, Embase, Web of Science and the Cochrane Library were searched from inception to August 2025. Randomized controlled trials (RCTs) comparing the Epley, Semont, Brandt–Daroff, and other repositioning maneuvers for posterior canal BPPV were included. Two reviewers independently performed literature screening, data extraction and risk-of-bias assessment. Network meta-analysis and league tables were generated using StataSE 15 and R 4.4.3, respectively.

Twenty RCTs involving 2,089 patients were included. The Epley maneuver ranked highest in overall effectiveness, with a surface under the cumulative ranking curve (SUCRA) of 97.84%, and was significantly superior to the Semont maneuver (RR = 1.04), the Brandt–Daroff maneuver (RR = 1.35) and control (RR = 1.30). For cure rate, the Epley and Semont maneuvers performed best and were significantly more effective than other interventions. For recurrence rate, the quality of evidence was generally low, and no optimal strategy could be identified. For safety, the incidence of nausea, vomiting and dizziness showed no statistically significant differences among the Epley, Semont and Brandt–Daroff maneuvers, although SUCRA rankings indicated a more favorable safety profile for the Epley maneuver.

The Epley and Semont maneuvers demonstrated optimal short-term efficacy (effectiveness and cure rate) with favorable safety profiles for posterior canal BPPV and should be recommended as first-line repositioning strategies. Future high-quality studies are needed to clarify the long-term effects on recurrence and applicability in specific populations.

https://www.crd.york.ac.uk/PROSPERO, identifier CRD420250653366.

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