How do I perform the Epley maneuver for benign paroxysmal positional vertigo (BPPV)?

How to Perform the Epley Maneuver for Posterior Canal BPPV

The Epley maneuver is a highly effective canalith repositioning procedure that should be performed as first-line treatment for posterior canal BPPV, with success rates of 80-93% after initial treatment and up to 90-98% with repeat sessions if needed. 1

Step-by-Step Technique

The American Academy of Otolaryngology-Head and Neck Surgery provides the following standardized sequence 1:

Step 1: Initial Positioning

• Seat the patient upright on the examination table
• Turn the patient's head 45° toward the affected ear (the ear that was positive on the Dix-Hallpike test) 1

Step 2: Supine Head-Hanging Position

• Rapidly lay the patient back to a supine position with the head hanging 20° below horizontal
• Maintain this position for 20-30 seconds 1
• The patient may experience vertigo and nystagmus during this step 1

Step 3: First Head Turn

• Turn the patient's head 90° toward the unaffected (opposite) side
• Hold this position for approximately 20 seconds 1

Step 4: Body Roll to Lateral Decubitus

• Turn the head an additional 90° in the same direction (total 180° from starting position)
• This typically requires the patient's body to roll from supine to lateral decubitus position
• The patient's head should now be nearly face-down
• Hold this position for 20-30 seconds 1

Step 5: Return to Upright

• Bring the patient back to the upright sitting position, completing the maneuver 1

Critical Post-Procedure Instructions

Do NOT impose postprocedural restrictions. The American Academy of Otolaryngology-Head and Neck Surgery provides strong evidence-based recommendations against routine postural restrictions, head elevation requirements, or activity limitations after the Epley maneuver. 1 Patients can resume normal activities immediately, including sleeping in any position. 1

Treatment Efficacy and Repeat Sessions

• Single treatment achieves 80-93% success rates 1, 2, 3
• If symptoms persist at 1-2 week follow-up, repeat the Dix-Hallpike test to confirm persistent BPPV 1
• Repeat maneuvers can be performed up to 3 times, achieving cumulative success rates of 90-98% 1, 2
• The average patient requires 1.2 maneuvers for complete resolution 2

Common Pitfalls and How to Avoid Them

Identifying the correct ear: The affected ear is determined by which side produces characteristic torsional upbeating nystagmus during the Dix-Hallpike test. 4 Always perform bilateral Dix-Hallpike testing if the first side is negative. 4

Speed of movement: Movements between positions should be relatively rapid, particularly the transition from sitting to supine head-hanging position. 1 Slow movements may reduce effectiveness. 5

Timing at each position: Maintain each position for the full 20-30 seconds even if symptoms resolve earlier, as this allows adequate time for otoconia migration. 1

Canal conversion: Approximately 6-7% of patients may develop horizontal canal BPPV during treatment. 5 If new horizontal nystagmus appears, perform the supine roll test and treat accordingly. 5

When Treatment Fails

If symptoms persist after 2-3 properly performed maneuvers 1:

• Repeat diagnostic testing to confirm persistent posterior canal involvement 1
• Evaluate for multiple canal involvement or bilateral BPPV 1
• Consider horizontal canal BPPV using the supine roll test 1
• Assess for coexisting vestibular pathology if symptoms occur with general head movements 1
• Rule out central causes if atypical features are present (vertical nystagmus, severe imbalance, neurological signs) 1

Special Populations Requiring Caution

Exercise caution in patients with 4:

• Severe cervical stenosis or radiculopathy
• Severe rheumatoid arthritis affecting the cervical spine
• Significant vascular disease
• Severe kyphoscoliosis
• Morbid obesity

For these patients, consider modified approaches, vestibular rehabilitation therapy, or referral to specialized vestibular physical therapy. 5

Medication Management

Do NOT routinely prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) for BPPV treatment. 5 These medications have no evidence of effectiveness as definitive treatment, may interfere with central compensation mechanisms, and cause adverse effects including drowsiness, cognitive deficits, and increased fall risk. 5 They may only be considered for short-term management of severe nausea/vomiting in severely symptomatic patients. 5