Can the Epley maneuver be used to treat vertigo in a patient with a concussion?

Epley Maneuver for Vertigo in Concussion Patients

The Epley maneuver can and should be used to treat vertigo in patients with concussion when benign paroxysmal positional vertigo (BPPV) is diagnosed through appropriate positional testing. 1, 2

Diagnostic Approach for Post-Concussion Vertigo

When evaluating vertigo in a concussion patient, it's critical to determine if BPPV is present:

1. Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV

   • Look for characteristic torsional, upbeating nystagmus
   • Note the latency period (typically 5-20 seconds)
   • Observe if vertigo and nystagmus resolve within 60 seconds
   • Test both sides 1

2. Perform supine roll test if Dix-Hallpike is negative but BPPV is still suspected

   • This helps identify lateral (horizontal) canal BPPV 1

Treatment Algorithm

If BPPV is confirmed:

1. Perform the Epley maneuver (canalith repositioning procedure)

   • This is the first-line treatment for posterior canal BPPV
   • No postprocedural restrictions are necessary 1

2. Reassess within 1 month to document resolution or persistence

   • If symptoms persist, repeat the Epley maneuver 1
   • Post-traumatic BPPV may require multiple treatments (up to 67% of cases vs 14% for non-traumatic cases) 1

Special Considerations for Concussion Patients:

• Post-traumatic BPPV is common but underdiagnosed, occurring in approximately 29.4% of pediatric patients with post-concussion dizziness 3
• Post-traumatic BPPV patients are generally younger, report more severe symptoms, and have higher relapse rates 2
• BPPV may be bilateral in rare instances following trauma 1

Cautions and Contraindications

Exercise caution when performing the Dix-Hallpike or Epley maneuver in patients with:

• Significant vascular disease
• Cervical stenosis
• Limited cervical range of motion
• Severe kyphoscoliosis
• Cervical radiculopathies 1

When to Consider Additional Evaluation

Obtain imaging or additional testing if:

• Symptoms are atypical for BPPV
• Positional testing is inconclusive
• Neurological signs inconsistent with BPPV are present
• Patient fails to respond to repositioning maneuvers after 2-3 attempts 1

Integration with Other Post-Concussion Treatments

For comprehensive management of post-concussion symptoms, consider sequencing treatments:

1. Address cervical dysfunction and BPPV early (first three weeks)
2. Integrate vision and vestibular therapy afterward 4
3. Consider sub-symptom threshold aerobic exercise, cognitive rehabilitation, and other therapies as needed 5

Early diagnosis and treatment of BPPV in concussion patients can expedite recovery from dizziness and may hasten overall recovery from concussion symptoms 3.