Timing of Repeat Epley Maneuver for BPPV
A second Epley maneuver can be performed immediately during the same visit if symptoms persist after the first attempt, or repeated every 2-3 days in the outpatient setting until symptoms resolve. 1
Immediate Repeat Treatment Protocol
If the Dix-Hallpike test remains positive after the first Epley maneuver, the procedure should be repeated during the same visit. 1
There is considerable variability in clinical practice—some clinicians perform only one cycle at initial treatment, while others repeat a fixed number of cycles or perform the maneuver repeatedly until vertigo symptoms extinguish during the same session. 1
Approximately 70% of patients achieve resolution of vertigo within 48 hours after a single treatment, but an additional 13% require a second maneuver performed 48 hours later. 2
Short-Interval Repeat Treatment
For persistent BPPV, the Epley maneuver can be repeated every 2-3 days in the outpatient clinic with excellent success rates. 3
Studies demonstrate that 86.7% of patients with persistent BPPV achieve resolution after frequently repeated canalith repositioning procedures performed at 2-3 day intervals. 3
The interval time between positions during the maneuver itself (15 seconds vs. 120 seconds) does not affect success rates, so shorter treatment times are equally effective and reduce patient burden. 4
Cumulative Success Rates
Initial success rate is approximately 80% with 1-3 treatments, increasing to 90-98% when additional repositioning maneuvers are performed for persistent BPPV. 5, 1
After one maneuver: 70% resolution within 48 hours 6
After two maneuvers: 74% cumulative resolution 6
After three maneuvers: 93.4% cumulative resolution 7
Long-term success: 92% remain symptom-free at mean 46-month follow-up 2
Follow-Up and Reassessment Timeline
Patients should be reassessed within one month after initial treatment to confirm symptom resolution or identify treatment failures. 1
Short-term follow-up should occur at 48 hours and 7 days after initial treatment to determine if repeat maneuvers are needed. 2
This one-month interval balances between overly early and unduly delayed reassessment. 1
Treatment Failure Considerations
Only 4% of patients manifest persistent BPPV after four treatments. 6
If symptoms persist after multiple attempts, reevaluate for:
Persistent BPPV is most commonly detected in the lateral semicircular canals, while recurrent BPPV most commonly affects the posterior canals. 3
Common Pitfalls to Avoid
Failing to repeat the Dix-Hallpike test after treatment to confirm whether BPPV persists—this is essential for determining if additional maneuvers are needed. 1
Waiting too long between repeat treatments when symptoms clearly persist—there is no evidence requiring a mandatory waiting period between maneuvers. 3
Not recognizing canal conversion, which requires repositioning for the newly affected canal rather than repeating the same maneuver. 5, 1
Prescribing vestibular suppressant medications instead of performing repeat repositioning maneuvers, as medications are not effective for treating BPPV. 5, 8