Epley Maneuver: Understand Why it Works and Follow Simple Instructions (Printable PDF Handout)

Note: full step-by-step info-graphic describing every detail of performing Epley Maneuver is at the bottom of this post.

If you’ve ever experience bouts of vertigo when you make certain head movements, such as getting out of bed or rolling over in bed, you may be suffering from a condition called benign paroxysmal positional vertigo (BPPV). This condition can be frustrating to deal with and can drastically affect your quality of life.

Explaining Benign Paroxysmal Positional Vertigo (BPPV)

Vertigo is a type of dizziness, which is defined as the illusion of movement that is the result of a mismatch of information between your visual, vestibular, and proprioceptive systems. 

Vertigo is categorized as either central or peripheral. Generally, central vertigo is usually more serious and peripheral vertigo is more benign in nature. 

Estimates have shown that between 45% and 54% of patients that go to their doctor with the complaint of dizziness are diagnosed with vertigo and benign paroxysmal positional vertigo (BPPV) is reported to be the most common cause vertigo.

BPPV is caused by displaced otoconia (small particles of calcium, sometimes referred to as otoliths). These otoconia are ordinarily attached to the utricle membrane in the ear. Trauma, aging, and infection can cause the otoliths to detach from the utricle. 

However, in approximately 50% of cases, the underlying cause is unknown (idiopathic). Once the otoliths become detached, they accumulate within the semicircular canal. The posterior semicircular canal is the most commonly affected canal, followed by the lateral (horizontal), and rarely, the superior (anterior) canal. Head movement cause the otoliths to trigger receptors in the semicircular canal that send faulty signals to the brain resulting in vertigo and nystagmus (abnormal eye movements).

There are two variants of BPPV, and it’s important to distinguish between the two as treatment varies:

1. ‍Canalithiasis

• loose crystals move freely in the fluid of the semicircular canal,
• takes less than 60 seconds for the crystals to stop moving after a change in head position has triggered the vertigo,
• once the crystals stop moving, the nystagmus and vertigo stop.

2. ‍Cupulolithiasis

• crystals are believed to be stuck on the nerve bundles that sense movement of fluid,
• the nystagmus and vertigo continue until the head is moved out of the position that has triggered the episode.

Statistically, BPPV tends to afflict women twice as often as men, and individuals are often affected during their 40’s and 50’s – with 49 years being the mean age of symptoms onset. Lifetime prevalence rates have been reported to be approximately 2.4%, and by the age of 80 years, incidence rates reach almost 10%.

The characteristic symptom of BPPV is intermittent vertigo (a sensation of spinning) that is brought on by a change in head position with respect to gravity (i.e. getting out of bed, rolling over in bed, tilting head backwards or forwards). Vertigo typically resolves within 30 seconds for individuals with posterior canal BPPV. In patients with horizontal canal BPPV, the vertigo can last upwards of a minute. However, some patients may have nonspecific dizziness, lightheadedness, postural instability, and nausea. 

While symptoms typically resolve spontaneously within 2 weeks, they may last up to several months in some individuals. BPPV typically occur in clusters and symptoms tend to recur after periods of remission.

Diagnosis of posterior semicircular canal BPPV is confirmed with the Dix-Hallpike test. A positive Dix-Hallpike test will show features of positional nystagmus. It is important to note that the Dix-Hallpike test will not have positive findings in patients with anterior or horizontal semicircular canal BPPV.

The Dix-Hallpike test provokes the patient’s vertigo and torsional nystagmus when they are moved from a seated position into a lying position, with their head rotated 45 degrees towards the affected ear, and their head is tilted 45 degrees below horizontal. Typically, the nystagmus presents after a few seconds and fatigues after approximately 30-40 seconds. Further, the nystagmus adapts with repetitive testing, resulting in a less vigorous response.

What Is the Epley Maneuver?

The (sometimes referred to as canalith repositioning) is named after Dr.John Epley, and is procedure that uses a series of head movements to treat posterior semicircular canal benign paroxysmal positional vertigo (BPPV).

The Epley maneuver is based on the canalithiasis theory and involves rotating the posterior semicircular canal backwards, close to its planar orientation. 

This position uses gravitational forces to help direct canaliths out of the posterior canal, back into the utricle, where they no longer interfere with the dynamics of the semicircular canal. Originally, the Epley maneuver involved sedation and mechanical skull vibrations; however, a modified Epley maneuver has been developed that does not utilized skull vibrations or sedation. 

The modified version of the Epley maneuver has been shown to be equally effective and easier to administer compared to the original technique.

How is the Epley Maneuver Performed?

Note: full step-by-step info-graphic describing every detail of performing Epley Maneuver is at the bottom of this post.

The maneuver takes place on the practitioner’s table and usually takes 10 to 15 minutes to complete. 

During treatment, each head position is held until nystagmus resolves, or for at least 30 seconds. Movements between each position are rapid. During the Epley maneuver, you may experience vertigo, as well as nausea and possibly vomiting.

The rules:

• The patient starts sitting upright with their head turned 45 degrees to the affected side.
• They are laid backward with their head hanging about 30 degrees over the edge of the couch and the affected ear to the ground.
• Next, their head is rotated by 90 degrees to face the opposite side.
• The head is held here as the patient rolls their body onto its side.
• The head is rotated so they are facing downward with their nose 45 degrees below horizontal.
• The patient sits up sideways keeping the head in position.

After treatment, you may have a sensation of light-headedness and have slight difficulty with balancing for a few days after treatment. You should wait in your doctor’s office for at least 10 minutes after completion of the maneuver and should avoid driving yourself home.

In some cases, your practitioner may recommend that you continue to perform the Epley maneuver at home, especially if you do not respond to a single treatment, or if you have frequent recurrence of your BPPV symptoms. For patients that continue with the maneuver at home, an aid may be recommended in some cases for conducting the treatment yourself. The DizzyFix, for example, is a device worn to help you perform the Epley maneuver properly.

This animation video provides a great explanation of BPPV and how the Epley maneuver helps to treat posterior canal BPPV. This video has been viewed over a million times and shows a physical therapist using the Epley maneuver on a patient experiencing BPPV. If your practitioner advises you to continue with the Epley maneuver at home, take a look at this video that explains how to perform the home Epley maneuver step by step for the treatment of posterior canal BPPV.

It is important to note that the Epley maneuver is only effective for treating BPPV of the posterior semicircular canal. If you have used the Epley maneuver and your symptoms persist, your BPPV may be affecting a different semicircular canal, or your vertigo may be caused by another condition. It is best to be re-evaluated by your practitioner to determine further treatment options.

Effectiveness of Epley Maneuver

High success rates have been found with the Epley maneuver, dating back to the initial use of this procedure by Epley.‍

Uncontrolled study results:

• In 1992, Epley reported a 100% success rate in 30 patients, in his initial description of the maneuver.
• In 1993, Parnes and Prince-Jones found a positive result in 79% of their participants using the Epley maneuver.
• In 2000, Nunez, Cass, and Furman found complete symptom resolution in 91.3% of their participants after 1-2 sessions of the Epley maneuver.
• Reinink et. al conducted a systematic review of the literature in 2014 and discovered that in 32% to 90% of patients, the first treatment session with Epley maneuver was successful. The success percentages ranged from 40% -100% after the second session with, 67% -98% after the third session, and 87%-100% after the fourth session, and 100% in the studies in which patients received 5 sessions.
• In 2015, Hughes, Shakir, Goggins, and Snow performed a retrospective study and found that symptomatic control was obtained following a single Epley maneuver for 47% of patients, and after three sessions for 84% of patients

Controlled study results:

• In 2003, Yimtae et al found that improvement was seen in 76% of patients treated with Epley maneuver compared to only 48% in untreated control subjects at 1 month following treatment.
• In 2005, Wietske et al found that subjective improvement was significantly higher in patients that received treatment with the Epley maneuver compared to the control group at 1 month (89% vs. 10%), and at 6 month follow up (92% vs. 50%).
• In 2006, von Brevern et al found that 80% of patients receiving Epley maneuver had neither nystagmus nor vertigo on positional testing, compared to only 10% in the control group 24 hours after treatment

Despite high success rates for the treatment of posterior canal BPPV using the Epley maneuver, BPPV tends to. Approximately 30% of patients have a recurrence within the first year after treatment, approximately of patients have a recurrence within 2 years after treatment, and about 50% of patients have a recurrence within 5 years of treatment.

Risks of epley maneuver

Epley maneuver is generally considered a safe treatment option. However, if you’re doing the Epley maneuver at home, you may want to have someone with you in case your symptoms become too intense and you need help.

While no serious adverse events have been reported, nausea during the maneuver varies from 16.7% to 32%, vomiting is rarely reported, and some patients are unable to tolerate the maneuvers because of cervical spine issues. In rare cases, the canaliths may move to another semicircular canal and continue to produce vertigo.

Contradictions to the epley maneuver

There are a few conditions in which the Epley maneuver is contraindicated, meaning it should be avoided, including:

• spinal stenosis of the cervical spine (neck)
• severe kyphoscoliosis
• limited neck mobility
• Down’s syndrome
• rheumatoid arthritis (advanced)
• cervical radiculopathies
• Paget’s disease
• morbid obesity
• ankylosing spondylitis
• severe lower back dysfunction
• spinal cord injuries

How should I prepare for the epley maneuver?

Before treatment, health professionals recommend you:

• Inform your doctor if you have neck or back problems as the exercise involves rotating the head.
• Tell your doctor of any problems with high blood pressure or history of a detached retina.
• Don’t eat for a few hours as the maneuver can trigger vertigo and nausea.
• Take any medications you have been prescribed to prevent vertigo and nausea symptoms.

What should I do after treatment?

After treatment, avoid symptom provoking head positions that may bring on your BPPV symptoms again. 

Additionally, the American Hearing Research Foundation suggests that you follow the following these tips in the week following treatment with the Epley maneuver:

• use multiple (2) pillows when you’re sleeping
• try to stay as upright as possible
• avoid sleeping on the affected side
• possibly use a soft cervical collar to maintain a neutral head position
• avoid extending your head backwards when lying on your back, especially when your head is turned towards the affected side
• avoid low back exercises
• avoid abdominal crunches/sit-ups
• avoid “crawl” type swimming movement

In conclusion

If you suffer from BPPV, you should consider asking your healthcare professional about performing the Epley maneuver. 

The research supports this maneuver for the treatment of posterior canal BPPV. 

It is considered a safe, effective, and relatively simple procedure to perform to relieve symptoms associated with posterior canal BPPV. Undergoing this treatment may help to alleviate your symptoms and improve your quality of life.

Testimonials

These patients tried Epley maneuver to control their symptoms and shared outstanding results they had:

S.B Perth, 35-44 Male (Patient) - One Sunday night as I was getting into bed, I got a major case of the head spins when I lay back with my head to the left. The next night I had the same thing happen but more violently. This continued every night as well as when I looked up at the ceiling at any time. I recall during the day of the first head spinning episode, I had been at the beach and had been diving off a pontoon into the ocean and doing a somersault as I entered the water. I had done this hundreds of times before. After doing some research and figuring out that I didn't have a brain tumor, I realized that I most likely had a case of BPPV (benign paroxysmal positional vertigo). I researched further and read about self-performing the Employ maneuver. After having head spins every time I lay down or looked up for about 4 weeks, I decided to give the Epley maneuver a go myself. I did exactly as the instructions said, the whole process taking about 2 minutes. I did it before I went to work in the morning so I could stay upright for as long as possible that day before lying down again. It worked first time! My vertigo was gone. That was about 4 weeks back and I have not had the slightest hint of any head spins since. I have even been for surfing lessons and been tumbled around in the waves with no re occurrence. If you have BPPV then you must try this at home yourself. It is only a couple of minutes of bad head spins you have to put up with. Better than weeks or months of it!

Alison - “One morning I discovered that I had extreme dizziness and nausea. I did not know what caused it and it had never happened to me before and the symptoms would not diminish. The dizziness/vertigo was particularly bad when I turned from side to side in bed. I went to my GP and she referred me to the Sandycove clinic. I was seen by Cathy Prenderville. She was thoroughly professional and explained a number of test manoeuvres she would perform to establish a diagnosis. She explained that when I turned my head and felt extreme dizziness she was able to see this by the rapid movement of my eyes. She was thus able to confirm that I had a condition known as BPPV. She provided me with a printed document which explained the condition very clearly. I was so relieved to know that there was a cause for the discomfort I had been feeling. She explained that the crystals in my inner ear had become dislodged and needed to be “re-settled” back into the correct position. She proceeded to carefully guide me through various positionings of the head and upper body (the Epley Manoeuvre). I did feel very nauseous at one point but Ms Prenderville had warned me that this was an unfortunate side effect of the treatment. The total session was completed in under an hour. I was given time to recover from the nausea and was well enough to drive myself home. That evening I was aware that I no longer felt nauseous and I no longer suffered from dizziness when turning my head on the pillow. I was absolutely delighted! I returned to the clinic on Thursday 21st February to check if the treatment had worked. Ms Prenderville assessed me again and was able to ascertain that I did not have the rapid eye movements associated with the previous dizziness. I felt totally well again.”

J. Mansbach -In 2010 I sought help from my doctor for a sudden and severe bout of dizziness. He told me I had BPPV and suggested I see a physical therapist that specialized in this area. My first encounter with Lucia Jimenez at Elmhurst Physical Therapy set my mind at ease. She instantly made me feel that she could help me. After thoroughly reviewing my medical history and symptoms, she ran a series of tests. What impressed me most is the way she took the time to explain how the inner ear works and why this was happening to me. She performed the Epley Maneuver to help alleviate the dizziness. It helped almost immediately and with a plan of special exercises I saw results and began to feel like myself again. The facility has the most amazing equipment for this condition. I have had several subsequent episodes through the years and knowing Ms. Jimenez is there to help me is so reassuring.

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What if didn't work?

Look at this professional perspective of increasing your odds to success with BPPV treatment here.

Epley maneuver infographic (brochure, pdf)

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