Epley Manoeuvre for BPPV Vertigo: Steps, Risks, Results

What the Epley manoeuvre does, briefly

The Epley manoeuvre, sometimes called the ear crystal manoeuvre, treats vertigo caused by BPPV. You move through a short sequence of head and body positions, holding each for 30 to 60 seconds, so that gravity carries loose crystals out of the balance canal. NHS hospital leaflets report that one treatment clears symptoms in about 8 or 9 cases in 10, and a repeat session can help if it does not, but it only works when aimed at the correct ear and canal, so assessment first is best.

For a short definition, see what is the Epley manoeuvre. This guide covers the steps, the risks and how to tell whether it has worked.

The Epley manoeuvre is a sequence of head and body positions used to treat benign paroxysmal positional vertigo (BPPV), one of the most common causes of vertigo. It works by using gravity to move displaced crystals out of the balance canal in the inner ear and back to where they belong.

When it is the right treatment and it is performed correctly, it works well and often quickly. Two conditions in that sentence do a lot of work, and this article covers both.

What BPPV actually is

Inside your inner ear are small calcium carbonate crystals, normally sitting in a chamber where they help detect head position relative to gravity.

In BPPV these crystals become displaced into one of the semicircular canals, which detect rotation. When you move your head, the loose crystals move through fluid in the canal and stimulate it inappropriately. Your brain receives a signal saying you are spinning when you are not, and vertigo results.

This explains the characteristic pattern:

• Triggered by specific head movements, especially rolling over in bed, lying down, sitting up, or looking up
• Brief, usually under a minute
• Intense spinning rather than vague lightheadedness
• Frequently worse in the morning
• No hearing loss or tinnitus

If that does not match your symptoms, the Epley manoeuvre is probably not your treatment.

For a fuller explanation of the condition and its treatment options, read what is BPPV and how is it treated.

BPPV symptoms

The defining symptom of BPPV is a short, intense spinning sensation brought on by a change in head position. Alongside it, people commonly report:

• Nausea during or after an episode, and occasionally vomiting
• Feeling unsteady or slightly off balance between episodes
• A brief delay of a few seconds between the head movement and the spinning starting
• Flickering, involuntary eye movements during an episode, which a clinician uses to confirm the diagnosis

Some symptoms point away from BPPV. Hearing loss, ringing in the ear, a feeling of fullness in the ear, vertigo that lasts for hours, fainting and new headaches are not features of BPPV and need a different assessment.

What causes BPPV? Ear crystals explained

The "ear crystals" involved in BPPV are called otoconia. They are tiny calcium carbonate particles that normally sit on a gel layer in a part of the inner ear called the utricle. BPPV begins when some of them break loose and drift into a semicircular canal.

In most cases no specific cause is found. Known contributors include:

• Age, as NHS leaflets from York and Scarborough and East Kent hospitals note that BPPV is most common in people over 40
• A head injury, even a minor one
• A previous inner ear problem such as vestibular neuritis or labyrinthitis
• Long periods with the head tilted back or lying flat, for example dental work, surgery or bed rest

None of these change the treatment. Whatever dislodged the crystals, repositioning is how they are moved back.

How long does BPPV last?

Each episode of spinning is short, usually under a minute. The condition itself lasts longer. Left alone, BPPV often settles on its own after several weeks, according to East Kent Hospitals. With a correctly aimed repositioning manoeuvre, East Kent Hospitals reports that one treatment stops symptoms in about 8 in 10 cases, with a good chance that a repeat session a week or so later works if the first does not.

A mild floating or unsteady feeling can linger for a few days to a couple of weeks after successful treatment. That is residual dizziness rather than a sign the manoeuvre failed. Vertigo that continues for months despite treatment is a reason to revisit the diagnosis.

Why assessment comes first

The Epley manoeuvre is widely available online, and plenty of people attempt it at home. The reason to be assessed first is not that it is dangerous, but that it is specific.

There is more than one canal. BPPV most often affects the posterior canal, which the Epley treats. It can also affect the horizontal canal, which requires a different manoeuvre entirely. Performing an Epley for horizontal canal BPPV does not help and can move crystals into a less favourable position.

It is side-specific. The manoeuvre must be performed toward the affected ear. Guessing wrong means it does not work, and people conclude the treatment failed when it was simply aimed at the wrong side.

It may not be BPPV at all. Vestibular migraine, PPPD, cervicogenic dizziness and other causes present with dizziness but do not respond to repositioning. Attempting Epley repeatedly for a condition it cannot treat wastes weeks.

A clinician determines which canal and which side using positional testing, most commonly the Dix-Hallpike test, then treats accordingly. This is why assessment often produces results where self-treatment did not.

The Dix-Hallpike test

The Dix-Hallpike test is how posterior canal BPPV is confirmed. You sit on the treatment couch with your head turned 45 degrees to one side. The clinician then lowers you quickly onto your back with your head tilted slightly below the level of the couch, and watches your eyes for up to a minute.

A positive test has a recognisable pattern. After a delay of a few seconds, vertigo starts together with a twisting, upward-beating eye movement, which is how the American Academy of Otolaryngology guideline defines posterior canal BPPV. Both fade within a minute. The test is repeated with the head turned the other way, and the side that provokes the response is the side to treat. Horizontal canal BPPV is checked with a different test, the supine roll test, which is why a negative Dix-Hallpike does not always rule BPPV out.

What happens during treatment

You will be asked about your symptoms, particularly the triggers and duration, then taken through positional testing. This will usually provoke your vertigo briefly, which is uncomfortable but diagnostically necessary, and the clinician watches for a characteristic eye movement that identifies the affected canal.

The repositioning manoeuvre itself involves being moved through a sequence of positions, holding each while symptoms settle. The whole sequence takes a few minutes and may be repeated.

Afterwards you may feel unsteady or slightly off for a day or two. That is normal. Many people notice a substantial difference immediately.

Advice on what to do in the following 24 to 48 hours varies between clinicians, and the American Academy of Otolaryngology guideline recommends against routine restrictions on posture after treatment. Follow whatever your clinician advises.

The Epley manoeuvre step by step

This is what the Epley manoeuvre (spelled Epley maneuver in the United States) involves for the right ear. For the left ear every direction is reversed.

1. Sit upright on the couch with your head turned 45 degrees to the right.
2. Lie back quickly, keeping your head turned, so that it rests tilted slightly back. Hold for 30 to 60 seconds, or until any vertigo stops.
3. Without lifting your head, turn it 90 degrees to the left. Hold for 30 to 60 seconds.
4. Roll onto your left side, turning your head a further 90 degrees so that your nose points towards the floor. Hold for 30 to 60 seconds.
5. Sit up slowly on the left side of the couch with your chin slightly tucked, and stay seated for a few minutes.

The steps look simple on paper. What makes them work is performing them towards the correct ear, for the correct canal, at the right speed and angles. That is the reason for assessment first, and the cautions later in this article apply before trying anything at home.

How effective is it?

Repositioning manoeuvres for posterior canal BPPV are well supported by evidence and are the recommended treatment. A Cochrane review found the Epley manoeuvre to be a safe, effective treatment: in the trials it included, vertigo resolved in about 56% of people after Epley compared with about 21% after a sham manoeuvre. York and Scarborough Teaching Hospitals reports that about 90% of cases clear with one manoeuvre, and some people need a repeat treatment.

If several correctly performed manoeuvres have not worked, that is useful information in itself. It usually means the diagnosis needs revisiting rather than that you need more repetitions.

Epley manoeuvre risks and side effects

The Epley manoeuvre is a low-risk treatment, but it is not side-effect free. The Cochrane review found no serious adverse effects, but nausea during the manoeuvre affected roughly 17% to 32% of people, and some could not tolerate it because of neck problems. The most common effects are:

• Vertigo and nausea during the manoeuvre. This is expected while the crystals move and usually passes within minutes.
• Unsteadiness afterwards. A floating or off-balance feeling for a day or two is common. Sit for a few minutes before standing, and take care on stairs.
• Crystals moving into a different canal. Occasionally the crystals shift into another canal, which changes the pattern of vertigo and needs a different manoeuvre. This is one reason to have it done by a clinician the first time.
• Neck strain. The head is turned and tilted back, which is why neck problems are on the cautions list below.

Recurrence

BPPV recurs relatively often: the Cochrane review reported a recurrence rate of 36% after treatment. This is not treatment failure; the crystals can become displaced again.

If it returns, it usually responds to the same treatment. Many people who have had it once recognise the pattern immediately and seek treatment early rather than waiting weeks again.

Vestibular rehabilitation exercises

Repositioning manoeuvres and vestibular rehabilitation exercises are different things, and the distinction matters.

Repositioning manoeuvres such as Epley physically move crystals. They treat BPPV specifically.

Vestibular rehabilitation exercises retrain the balance system through graded exposure to movement. They treat incomplete recovery after a vestibular event, PPPD, and general unsteadiness. They are not the first-line treatment for BPPV, although the American Academy of Otolaryngology guideline says vestibular rehabilitation may be offered as part of treatment.

Some people need both, typically repositioning first for the BPPV, then rehabilitation for residual unsteadiness. Programmes are individualised, progressive, and generally deliberately provoke mild symptoms in a controlled way, which is how the system recalibrates.

Epley manoeuvre vs Brandt-Daroff exercises

Both are used for BPPV, but they work differently. The Epley manoeuvre is a single guided sequence that moves the crystals out of the canal, usually performed by a clinician, and it often works in one to three sessions. Brandt-Daroff exercises are a home routine of repeated side-lying movements, done several times a day for around two weeks, that gradually disperse the crystals and reduce sensitivity to the movement.

The Epley manoeuvre has the higher success rate and is the first choice for posterior canal BPPV. In the one trial in the Cochrane review that compared them, a single Epley treatment was more effective than a week of Brandt-Daroff exercises done three times a day. Brandt-Daroff exercises are useful where a repositioning manoeuvre is not suitable, for mild symptoms that remain afterwards, or for people whose BPPV keeps returning. Our guide to Brandt-Daroff exercises explains how to do them.

When not to attempt anything at home

Seek medical assessment before attempting any manoeuvre if you have:

• Neck problems, recent neck injury, or significant cervical arthritis
• Recent head injury
• Retinal detachment or recent eye surgery
• Severe cardiovascular disease
• Any hearing loss or tinnitus with your vertigo
• Neurological symptoms of any kind

Call 999 or go to A&E if vertigo comes with a sudden severe headache, facial or limb weakness, slurred speech, double vision, severe difficulty walking, or sudden hearing loss. These can indicate a stroke. The NHS lists double vision or loss of vision, hearing loss, trouble speaking and weakness, numbness or tingling in an arm or leg with vertigo as reasons to call 999 or go to A&E.

Epley questions answered

Can I do the Epley manoeuvre myself?

Versions exist for home use, and clinicians sometimes teach them for recurrence. For a first episode, assessment first is strongly preferable, because the manoeuvre must match the canal and the side.

Will it make me feel sick?

It commonly provokes brief vertigo and sometimes nausea during the procedure. That is expected. Tell your clinician if you are prone to severe nausea, as it can be planned around.

How do I know if the Epley manoeuvre worked?

Often immediately, though mild unsteadiness for a day or two afterwards is normal and does not mean it failed. The clearest sign is that the movement that used to trigger spinning, such as rolling over in bed or looking up, no longer does. A clinician can confirm this by repeating the positional test: if it no longer provokes vertigo or the typical eye movement, the manoeuvre has worked.

What if it does not work?

Usually it means a different canal, a different side, or a different diagnosis. That is a reason for reassessment rather than repetition.

Is BPPV serious?

It is not dangerous in itself, which is what benign refers to, but it is unpleasant and it raises fall risk, which matters more with age.

Having the manoeuvre aimed correctly

Before any manoeuvre, our £50 vertigo and BPPV assessment and treatment pinpoints the canal and side involved, so the Epley is aimed rather than guessed, and treatment usually follows in the same session. Call 020 4515 0000 or book a session online and come to us at 8 to 9 Bedford Corner, The Avenue, Chiswick W4 1LZ.

Sources

• Cochrane: The Epley manoeuvre for benign paroxysmal positional vertigo
• Bhattacharyya N and others (2017), Otolaryngology Head and Neck Surgery: Clinical Practice Guideline, Benign Paroxysmal Positional Vertigo (Update)
• York and Scarborough Teaching Hospitals NHS Foundation Trust: Benign Paroxysmal Positional Vertigo (BPPV)
• East Kent Hospitals University NHS Foundation Trust: Benign Paroxysmal Positional Vertigo (BPPV)
• NHS: Vertigo
• NHS: Symptoms of a stroke

This article is general information, not medical advice, and is not a substitute for individual assessment. Do not attempt repositioning manoeuvres if any of the cautions above apply to you.