Horizontal vs. posterior canal BPPV: why doesn't the Epley maneuver work for everyone?

How do posterior and horizontal canal BPPV feel different?

Posterior canal BPPV is typically triggered by lying back, getting out of bed or looking up, and the Dix-Hallpike test reproduces it. Horizontal canal BPPV is triggered mostly by rolling side to side while lying down, often feels more intense and can last a little longer. The supine roll test reproduces it².

How do you know which canal and side are affected?

The eyes tell us. Under infrared video goggles, posterior canal BPPV produces upbeating, torsional nystagmus. Horizontal canal BPPV produces side-beating nystagmus that changes direction as you roll, either toward the ground (geotropic) or away from it (apogeotropic). Comparing its strength on each side shows which ear is involved².

Which maneuver treats which type of BPPV?

• Posterior canal: Epley (canalith repositioning) or Semont liberatory maneuver³
• Horizontal canal, geotropic: BBQ (Lempert) roll or Gufoni maneuver
• Horizontal canal, apogeotropic: maneuvers that free crystals from the cupula or convert them to the geotropic form first, then treat
• Anterior canal: a deep head-hanging maneuver

Where can I get the right BPPV maneuver near Alpharetta or Cumming?

At our Cumming and Alpharetta clinics, every BPPV maneuver is chosen from the recorded eye movements, and we retest after treatment to confirm the canal has cleared. Patients come from Johns Creek, Milton, Suwanee and Forsyth County, and urgent appointments are available within 48 hours.

Where can I get help in Alpharetta, Cumming and nearby?

Dr. Manan Patel, PT, DPT, TPS and our team of physical therapists see patients from Alpharetta, Johns Creek, Milton, Roswell, Cumming, Suwanee, Sugar Hill, Buford, Duluth and Forsyth County at two North Atlanta clinics. Every visit is 60 minutes, one-on-one, and urgent appointments are available within 48 hours. We are in-network with Traditional Medicare, BCBS / Anthem and Tricare, and offer a $129 rate per visit for self-pay and out-of-network plans. Not sure where to start? Take the free symptom self-check, or visit our Alpharetta clinic or Cumming clinic page.

Related care

Related questions

• Why are infrared video Frenzel goggles essential for an accurate BPPV diagnosis?In normal room light, your eyes can suppress nystagmus, the involuntary eye movement that reveals an inner ear…2 min read · Patient question
• Why does my BPPV keep coming back? Vitamin D, bone health, head injury and recurrenceBPPV often comes back: studies report recurrence in roughly 10 to 18% of people within a year, and in more over…2 min read · Patient question
• What are anterior canal and multi-canal BPPV, and how are they treated when standard tests fail?Anterior canal BPPV is the least common type and produces downbeating nystagmus during positional testing.…2 min read · Patient question
• All bppv and inner ear crystals questionsBrowse every question in this topic.

References

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

Answered 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 answer is general education, not a diagnosis or a substitute for an examination. If you have new or worsening symptoms, contact your doctor. Call 911 for sudden severe dizziness with trouble speaking, weakness, numbness, double vision or a severe headache.