What are the steps for the Benign Paroxysmal Positional Vertigo (BPPV) maneuver, also known as the Epley maneuver?

Steps for the Epley Maneuver for Posterior Canal BPPV

The Epley maneuver is the first-line treatment for posterior canal BPPV, performed through a standardized 5-step sequence that repositions displaced otoconia from the semicircular canal back into the vestibule, with success rates of 80-93% after a single treatment and up to 90-98% with repeat sessions. 1

Step-by-Step Technique

Step 1: Initial Positioning

• Begin with the patient seated upright on the examination table 1
• Turn the patient's head 45° toward the affected ear (the side that tested positive on Dix-Hallpike) 1

Step 2: Supine Head-Hanging Position

• Rapidly lay the patient back to a supine position with the head hanging 20° below horizontal 1
• Move quickly during this transition—speed is critical for effectiveness 1, 2
• Maintain this position for 20-30 seconds, even if symptoms resolve earlier 1
• This position allows otoconia to begin migrating through the canal 1

Step 3: First Head Turn

• Turn the patient's head 90° toward the unaffected side while maintaining the supine head-hanging position 1
• Hold for approximately 20-30 seconds 1

Step 4: Body Roll to Lateral Decubitus

• Turn the head an additional 90° in the same direction (now facing 180° from starting position) 1
• The patient's body must roll from supine to lateral decubitus position (lying on their side) 1
• Hold for 20-30 seconds 1

Step 5: Return to Sitting

• Bring the patient back to the upright sitting position 1
• The entire sequence is now complete 1

Critical Post-Procedure Instructions

Patients can resume normal activities immediately after the Epley maneuver—do NOT impose postural restrictions, head elevation requirements, or activity limitations. 1, 3

• The American Academy of Otolaryngology-Head and Neck Surgery provides strong evidence against routine postprocedural restrictions, as they provide no benefit and may cause unnecessary complications 1, 3

When to Repeat the Maneuver

• If symptoms persist at 1-2 week follow-up, repeat the Dix-Hallpike test to confirm persistent BPPV 1
• Repeat the Epley maneuver up to 3 times if the Dix-Hallpike remains positive 1
• Cumulative success rates reach 90-98% with repeat treatments 1, 4

Common Pitfalls and How to Avoid Them

Timing Errors

• Maintain each position for the full 20-30 seconds even if vertigo stops earlier—this allows adequate time for otoconia migration 1
• Rushing through positions or not holding long enough reduces effectiveness 1

Movement Speed

• The transition from sitting to supine head-hanging must be relatively rapid 1
• Slow movements may fail to adequately mobilize the otoconia 2

Wrong Canal Treatment

• Always confirm posterior canal involvement with Dix-Hallpike test before performing Epley maneuver 3
• If horizontal or no nystagmus appears on Dix-Hallpike, perform supine roll test to assess for lateral canal BPPV 3

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 canal conversion (changing from one canal type to another), which occurs in 6-7% of cases 5
• Consider multiple canal involvement or bilateral BPPV 1
• Assess for horizontal canal BPPV using the supine roll test 1
• Rule out coexisting vestibular pathology or central causes if atypical features present 5

Contraindications and Special Populations

Exercise caution or consider modified approaches in patients with: 1

• Severe cervical stenosis or radiculopathy 1
• Severe rheumatoid arthritis affecting the cervical spine 1
• Significant vascular disease 1
• Severe kyphoscoliosis 1
• Morbid obesity 1

For these patients, consider referral to specialized vestibular physical therapy or alternative treatments like Brandt-Daroff exercises 5

What NOT to Do

Do NOT routinely prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV treatment. 1, 3

• These medications have no evidence of effectiveness as definitive treatment 1
• They may interfere with central compensation mechanisms 1
• They cause adverse effects including drowsiness, cognitive deficits, and increased fall risk 5
• Consider them only for short-term management of severe nausea/vomiting in severely symptomatic patients 5