The Epley maneuver: when it works, and why the side matters

What BPPV is

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo.¹ Tiny calcium carbonate crystals, called otoconia, normally sit in a part of the inner ear called the utricle. When some break loose and drift into one of the three fluid-filled semicircular canals, the canal starts responding to head position. The result is a brief, intense spin when you roll over in bed, lie down, sit up or look up.

Spells usually last less than a minute but can leave you queasy and off balance for hours. BPPV becomes more common with age and can follow a head injury, a period of bed rest or another inner-ear problem.

Who gets BPPV

BPPV can happen at any age, but it is most common after age 50 and somewhat more common in women. A head injury, a long period lying in bed, inner-ear infections and Ménière's disease can all set it off. Often there is no clear trigger at all. If spinning started after a fall or car accident, read our concussion recovery guide as well, because BPPV often travels with concussion symptoms.

How the Epley maneuver works

The Epley maneuver is a canalith repositioning procedure. A clinician moves your head through a series of positions, holding each one while the crystals settle, so gravity guides them out of the posterior canal and back into the utricle, where they no longer cause spinning. The whole procedure takes a few minutes.

The BPPV clinical practice guideline recommends canalith repositioning as the treatment for posterior canal BPPV,¹ and a Cochrane review found the Epley maneuver safe and effective compared with sham treatment.²

Why the side and canal matter

Each inner ear has three canals: posterior, horizontal (lateral) and anterior. The Epley maneuver is designed for the posterior canal. Crystals in the horizontal canal need a different maneuver, such as the barbecue roll or the Gufoni maneuver, and the anterior canal needs another approach again. Crystals can also cling to the canal's sensor (cupulolithiasis) instead of floating freely, which changes the treatment.³

Doing the maneuver toward the wrong ear, or for the wrong canal, is a common reason home attempts from online videos do not work. It can also provoke strong vertigo and nausea without fixing anything.

How we confirm which canal is involved

We use infrared video goggles during positional tests such as the Dix-Hallpike and supine roll tests. The goggles block out light, so your eyes cannot suppress the involuntary movements (nystagmus) that BPPV causes. The direction and timing of those eye movements tell us which ear and which canal are involved, and whether the crystals are free-floating or stuck.

Staying safe until your appointment

• Sit on the edge of the bed for a moment before standing up in the morning.
• Turn your whole body rather than snapping your head when you look up or behind you.
• Avoid ladders, step stools and heights until the spinning is treated.
• Do not drive if spells come on without warning.
• Keep a light on at night and clear the path to the bathroom.

After treatment

• You can usually go about your normal day. The guideline advises against routine restrictions such as sleeping upright after the maneuver.¹
• Some people feel off balance or floaty for a few days afterward. This usually settles, and balance exercises can help.
• If the spinning comes back, BPPV may have returned or moved to another canal. Retesting tells us which.
• If you have had BPPV before, we can teach you a home maneuver for your specific ear and canal, so you can treat a recurrence early.

Medicines and BPPV

Medicines such as meclizine can ease nausea for a short time, but they do not move the crystals. The guideline recommends against routinely treating BPPV with vestibular suppressants such as antihistamines or benzodiazepines.¹

When it might not be BPPV

Positional dizziness is usually BPPV, but not always. Dizziness that is constant, or that comes with hearing loss, a severe headache, double vision or weakness, needs a broader evaluation.

Myth or fact?

Tap each statement to see what the evidence says.

Keep reading

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• Concussion recovery: why complete rest isn't the answerWhy brief rest and gradual activity beat a dark room, and when to get rehab.3 min read · Patients
• All guidesBrowse the full learning center.

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References

1. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery. 2017.
2. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews. 2014.
3. von Brevern M, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research. 2015.

Clinically reviewed by Dr. Manan Patel, PT, DPT, TPSDoctor of Physical Therapy, Certified Vestibular Specialist and one of the few certified Therapeutic Pain Specialists in North Atlanta, with 15+ years of outpatient care. About Dr. Patel

This guide is general education, not a diagnosis or a substitute for an examination. If you have new or worsening symptoms, contact your doctor.