How often should the Epley (canalith repositioning procedure) maneuver be performed?

How Often to Perform the Epley Maneuver for BPPV

The Epley maneuver should be performed 1-3 times during the initial treatment session, with repeat sessions scheduled if symptoms persist, typically reassessed within one month. 1

Initial Treatment Session Protocol

During the first visit, clinicians have flexibility in the number of cycles performed, though evidence supports repeating the maneuver until symptoms resolve or the Dix-Hallpike test converts to negative. 2 The American Academy of Otolaryngology-Head and Neck Surgery acknowledges considerable variability exists in clinical practice—some perform only one cycle while others repeat a fixed number or continue until vertigo extinguishes. 1

Evidence for Multiple Cycles in Same Session

• Performing multiple Epley maneuvers during the same session, followed by Dix-Hallpike retesting and an additional maneuver after negative conversion, shows superior outcomes compared to single maneuver approaches. 3
• One study demonstrated a positive odds ratio of 2.7 for recovery when comparing single maneuver versus multiple maneuvers with retesting, and 2.5 when adding an additional maneuver after negative Dix-Hallpike. 3

Expected Response Timeline

Approximately 70-80% of patients achieve complete vertigo resolution within 48 hours after the first Epley maneuver. 4, 1 Success rates are:

• 70% resolution after first treatment within 48 hours 4
• 80.5% negative Dix-Hallpike by day 7 5
• 37.7% asymptomatic after first session in one hospital-based study 6

Follow-Up and Repeat Treatment Protocol

Patients should be reassessed within one month after initial treatment to confirm symptom resolution. 1 This timing balances between overly early and unduly delayed reassessment. 1

When to Repeat the Maneuver

• If symptoms persist at follow-up, repeat the Epley maneuver during subsequent visits. 1
• 61.5% of patients require repeated sessions beyond the initial treatment 6
• Cumulative success rates reach 90-98% when additional repositioning maneuvers are performed for persistent BPPV. 1, 5
• The average patient receives 1.23 Epley maneuvers with a 93.4% success rate 7

Maximum Number of Attempts

If BPPV persists after three to four treatment sessions, consider the patient a treatment failure and reevaluate for alternative diagnoses or surgical options. 4, 7 Only 4% of cases persist after four treatments. 4

Important Clinical Considerations

Common Pitfalls to Avoid

• Failing to reassess patients after initial treatment leads to missed persistent BPPV or alternative diagnoses. 1
• Not recognizing canal conversion (6-7% of cases) during treatment, which requires repositioning for the newly affected canal. 1, 5
• Performing the maneuver too slowly reduces effectiveness 5
• Not performing Dix-Hallpike retesting between maneuvers in the same session may miss opportunities for additional benefit 3

Treatment Failures Require Reevaluation For:

• Persistent BPPV that may respond to additional repositioning 1
• Involvement of other semicircular canals 1
• Coexisting vestibular conditions 1
• Serious CNS disorders that may simulate BPPV 1

Post-Treatment Expectations

• No postprocedural restrictions are recommended after the Epley maneuver. 2, 5
• Mild residual symptoms of lightheadedness or imbalance occur in 47% of cases but rarely require formal vestibular rehabilitation 4
• BPPV has a high recurrence rate of 36% after successful treatment 8

Self-Treatment Option

Self-administered Epley maneuvers can be taught to motivated patients and are more effective (64% improvement) than Brandt-Daroff exercises (23% improvement). 5 This provides an option for patients between clinical visits or in settings where immediate specialist care is unavailable.