What are the steps to perform the Epley maneuver on an adult patient with benign paroxysmal positional vertigo (BPPV)?

How to Perform the Epley Maneuver

The Epley maneuver is the first-line treatment for posterior canal BPPV, performed through a standardized sequence of rapid head and body movements that achieve 80-93% success after a single session and 90-98% with repeat treatments. 1

Step-by-Step Technique

Position 1: Initial Setup

• Start 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

Position 2: Supine Head-Hanging

• Rapidly lay the patient back to a supine position with the head hanging 20° below horizontal 1
• Maintain this position for 20-30 seconds, even if symptoms resolve earlier 1
• This rapid movement from sitting to supine is critical for effectiveness 1
• Patients who report vertigo during this transition to the second position have 5.3 times higher odds of successful treatment 2

Position 3: Head Turn to Unaffected Side

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

Position 4: Body Roll to Lateral Decubitus

• Turn the head an additional 90° in the same direction, requiring the patient's body to roll from supine to lateral decubitus position 1
• The patient should now be lying on their side with their nose pointing toward the ground 1
• Hold for 20-30 seconds 1

Position 5: Return to Sitting

• Slowly bring the patient back to the upright sitting position 1

Critical Execution Points

Speed of Movement

• Movements between positions must be relatively rapid, particularly the transition from sitting to supine head-hanging position 1
• Failure to move the patient quickly enough reduces effectiveness 1

Duration at Each Position

• Maintain each position for the full 20-30 seconds even if vertigo stops earlier, allowing adequate time for otoconia migration 1

Post-Procedure Instructions

Activity Restrictions

• Patients can resume normal activities immediately after the Epley maneuver—do NOT impose postprocedural restrictions, head elevation requirements, or activity limitations 1
• The American Academy of Otolaryngology-Head and Neck Surgery provides strong evidence-based recommendations against routine postural restrictions 3, 1

Treatment Efficacy and Follow-Up

Expected Success Rates

• Single treatment achieves 80-93% success rates 1
• After a second maneuver, success rates reach 90-98% 1, 4
• Symptoms typically subside within 72 hours in 35% of patients and within one week in 74% of patients 5

When to Repeat

• 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 diagnostic test remains positive 1

Treatment Failure Protocol

• If symptoms persist after 2-3 properly performed maneuvers, reassess for: 1
  • Canal conversion (occurs in approximately 6% of cases) 1
  • Multiple canal involvement or bilateral BPPV 1
  • Horizontal canal BPPV using the supine roll test 1
  • Coexisting vestibular pathology 1
  • CNS disorders masquerading as BPPV if atypical features present 1

Common Pitfalls and How to Avoid Them

Technical Errors

• Not moving rapidly enough between positions—this is the most common technical error that reduces effectiveness 1
• Stopping too soon at each position—wait the full 20-30 seconds even if symptoms resolve 1
• Treating the wrong side—always confirm the affected side with Dix-Hallpike testing before treatment 1

Medication Errors

• Do NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) for BPPV treatment 1
• These medications have no evidence of effectiveness and may interfere with central compensation mechanisms 1
• They cause adverse effects including drowsiness, cognitive deficits, and increased fall risk 1

Special Populations Requiring Caution

Contraindications and Modified Approaches

• Exercise caution or consider alternatives 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 modified approaches or referral to specialized vestibular physical therapy 1

Self-Treatment Option

Teaching Patients Self-Administration

• Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment 1
• Self-administered CRP shows 64% improvement rates, significantly more effective than Brandt-Daroff exercises (23% improvement) 3, 1