Predictors of Early Failure in an Epley-First Approach for Posterior Canal Benign Paroxysmal Positional Vertigo in the Emergency Department.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness in the emergency department (ED), yet bedside diagnostic and therapeutic maneuvers remain underused, often leading to unnecessary imaging and resource utilization. STUDY OBJECTIVES: To evaluate the effectiveness of an Epley-first approach and identify predictors of early treatment failure in patients with posterior canal BPPV. METHODS: In this retrospective observational study, 774 adult ED patients with posterior canal BPPV were managed with the Epley maneuver as the initial treatment strategy. Early treatment success was defined as symptom resolution without the need for additional intervention within 60 min. Logistic regression analysis was performed to identify independent predictors of treatment failure. RESULTS: Early symptom resolution was achieved in 81.8% of patients, while 18.2% required additional interventions. Patients with treatment failure were significantly older and had longer symptom duration (both p < 0.001). In multivariable analysis, age (OR: 1.06, 95% CI: 1.04-1.08, p < 0.001) and symptom duration (OR: 1.03 per minute, 95% CI: 1.02-1.03, p < 0.001) were identified as independent predictors of failure. The predictive model demonstrated strong discriminative performance (AUC: 0.876). No newly identified focal neurological deficits suggestive of an acute central neurological disorder were documented during ED evaluation. CONCLUSIONS: The Epley-first approach was associated with rapid early symptom control in appropriately selected patients with posterior canal BPPV presenting to the ED. Age and symptom duration may facilitate early risk stratification and support more individualized diagnostic decision-making in appropriately selected patients.