Head Shaking Maneuver for Horizontal Cupulolithiasis

Description

The therapeutic head-shaking maneuver is a treatment technique described for apogeotropic or horizontal cupulolithiasis BPPV. It consists of repeated horizontal head movements, most often with the head flexed forward about 30°. Some studies describe the maneuver in a sitting position, while others describe it with the patient lying supine to better align the lateral canal with the plane of rotation (Oh et al., 2009; Kim et al., 2012; Kong et al., 2020; Lee et al., 2023).

A-045 Horzontal Canal Cupulolithiasis (2)

Effectiveness

Effectiveness varies across studies. Kong et al. reported a 12.5% initial response rate after one treatment, while Kim et al. reported a 62.3% response rate after up to two maneuvers on the initial visit day. Lee et al. reported improvement from 18.2% initially to 90.5% at 4 weeks. Overall, therapeutic head-shaking is an evidence-supported option for apogeotropic lateral canal BPPV, but it has not consistently shown superiority over other maneuvers.

History

The maneuver grew out of the challenge of treating apogeotropic lateral canal BPPV, which does not always respond as predictably as the more common geotropic form. Once clinicians recognized that apogeotropic nystagmus could reflect debris attached to the cupula or trapped in the anterior arm of the lateral canal, treatment strategies began shifting from simple repositioning to techniques meant to loosen or mobilize the debris first. Head-shaking was one of these strategies. It adapted a familiar vestibular examination movement into a therapeutic maneuver for apogeotropic horizontal canal BPPV, later gaining research attention in various studies.

Instructions

The purpose is to loosen and mobilize otoconia so they can move out of a position that is provoking horizontal cupulolithiasis BPPV.

Seated Version

Begin with the patient sitting upright.
Flex the patient’s head forward about 30°.
Hold the patient’s head securely.
Shake the head side to side in a horizontal, sinusoidal motion at approximately 3 Hz for 15 seconds.
Return the head to neutral.
Second repetition can be applied if no resolution after 30 min after first repetition.

Supine Version

Begin with the patient lying supine.
Flex the patient’s head forward about 30°.
Hold the patient’s head securely.
Shake the head horizontally about 30° to each side at approximately 2 Hz for 15 seconds.
Have the patient remain lying supine for 2 minutes.

Related Pathology

Horizontal cupulolithiasis

Sources

Kim JS, Oh SY, Lee SH, et al. Randomized clinical trial for apogeotropic horizontal canal benign paroxysmal positional vertigo. Neurology. 2012;78(3):159-166. doi:10.1212/WNL.0b013e31823fcd26 https://pubmed.ncbi.nlm.nih.gov/22170885/
Kong TH, Song MH, Kang JW, Shim DB. Double-blind randomized controlled trial on efficacy of cupulolith repositioning maneuver for treatment of apogeotropic horizontal canal benign paroxysmal positional vertigo. Acta Otolaryngol. 2020 Jun;140(6):473-478. doi: 10.1080/00016489.2020.1736339. Epub 2020 Mar 18. PMID: 32186237. https://pubmed.ncbi.nlm.nih.gov/32186237/
Lee HJ, Jeon EJ, Nam S, Mun SK, Yoo SY, Bu SH, Choi JW, Chung JH, Hong SM, Lee SH, Kim MB, Koo JW, Kim HJ, Seo JH, Ahn SK, Park SN, Kim M, Chung WH. Treatment Efficacy of Various Maneuvers for Lateral Canal Benign Paroxysmal Positional Vertigo With Apogeotropic Nystagmus: A Randomized Controlled Trial. Clin Exp Otorhinolaryngol. 2023 Aug;16(3):251-258. doi: 10.21053/ceo.2023.00619. Epub 2023 Jul 26. PMID: 37499698; PMCID: PMC10471904. https://pmc.ncbi.nlm.nih.gov/articles/PMC10471904
Oh SY, Kim JS, Jeong SH, Oh YM, Choi KD, Kim BK, Lee SH, Lee HS, Moon IS, Lee JJ. Treatment of apogeotropic benign positional vertigo: comparison of therapeutic head-shaking and modified Semont maneuver. J Neurol. 2009 Aug;256(8):1330-6. doi: 10.1007/s00415-009-5122-6. Epub 2009 Apr 12. PMID: 19363632. https://pubmed.ncbi.nlm.nih.gov/19363632/