Is nausea a normal reaction after undergoing Epley's maneuver?

Is Nausea Normal After Epley's Maneuver?

Yes, nausea is a completely normal and expected reaction after undergoing the Epley maneuver, occurring in approximately 16.7% to 32% of patients during the repositioning procedure. 1

What Patients Should Expect

Patients should be informed before the procedure that nausea, occasional vomiting, and/or a sense of falling may arise during the canalith repositioning procedure (CRP). 1 These symptoms are caused by the movement of displaced calcium carbonate crystals (otoconia) through the semicircular canals during the repositioning procedure. 2

Common Symptoms During and After the Maneuver

• Sudden onset of intense subjective vertigo that typically subsides within 60 seconds 2
• Nausea during the maneuver in 16.7% to 32% of patients 1, 3
• Occasional vomiting during or immediately after the procedure 1
• A sense of falling that may occur within 30 minutes after the maneuver 2
• Mild residual symptoms for a few days to weeks after successful treatment 4

Pre-Treatment Counseling and Management

Identifying High-Risk Patients

Clinicians should identify patients at higher risk for severe nausea and vomiting, including those with a history of motion sickness. 2 Patients who previously manifested severe nausea and/or vomiting with the Dix-Hallpike maneuver may be offered antiemetic prophylaxis 30 to 60 minutes prior to CRP. 1

During-Procedure Strategies

• Ensure proper positioning and support throughout the maneuver to minimize excessive movement that could exacerbate symptoms 2
• Maintain each position in the sequence for the recommended 20-30 seconds, allowing time for symptoms to subside before moving to the next position 2
• Move slowly between positions if the patient reports severe nausea 2

When Nausea Becomes Concerning

While nausea is normal, there is one documented case in the medical literature of a 77-year-old female who experienced severe nausea and vomiting with evolving visual changes immediately following the Epley maneuver, which was associated with an acute intraparenchymal hemorrhage in the occipital lobe. 5 However, the indirect causation and extreme rarity of this event (the first and sole case in medical literature) do not warrant any change to patterns of practice. 5

Red Flags Requiring Immediate Evaluation

Seek emergency evaluation if nausea is accompanied by:

• Evolving visual changes or visual field deficits 5
• Severe, persistent headache that differs from typical post-procedure discomfort 5
• Neurological symptoms beyond expected vertigo and nausea 5

Alternative Approaches for Patients Who Cannot Tolerate the Maneuver

For patients who cannot tolerate the Epley maneuver despite medication, consider alternative repositioning procedures such as the Semont liberatory maneuver, which has similar success rates to the Epley maneuver. 2 Some patients may be unable to tolerate CRP because of cervical spine problems. 1, 3

Important Context: Why the Maneuver Is Still Worth It

Despite the discomfort, the Epley maneuver has a success rate of approximately 80% with just 1-3 treatments 1, 4, and patients treated with CRP have a 6.5-times greater chance of improvement in clinical symptoms relative to controls. 1 The transient nausea is a small price to pay for the high likelihood of complete symptom resolution, especially when compared to the alternative of persistent vertigo and increased fall risk.