BPPV Vertigo at Home: Epley Maneuver & When to See a Doctor

What is BPPV and what causes it?

The inner ear contains three semicircular canals that sense head rotation. Each canal is filled with fluid and has a sensitive receptor area lined with hair cells. Tiny calcium carbonate crystals called otoliths (or canaliths) normally rest on a membrane in a different part of the inner ear. In BPPV, these crystals break loose and migrate into one of the canals — most often the posterior canal.

When you move your head, the displaced crystals create false movement signals, causing a sudden sensation of spinning that typically lasts less than one minute and stops when you hold still. It is often triggered by looking up, rolling over in bed, or bending forward.

BPPV can happen without a clear cause, though it is more common after head injury, inner ear infection, prolonged bed rest, or as part of normal aging. It is more prevalent in women and in older adults 1Ref 1Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).AAO-HNS recommendation of Epley maneuver as first-line treatment for posterior canal BPPV; support for patient self-treatment with appropriate instruction; watchful waiting as an alternative.

What is the Epley maneuver, and does it work?

The Epley maneuver (also called canalith repositioning procedure) uses a sequence of specific head and body positions to guide the loose crystals out of the semicircular canal and back to where they belong. A Cochrane systematic review found the Epley maneuver to be safe and effective for posterior canal BPPV, with most people experiencing significant improvement or resolution of symptoms 2Ref 2Hilton MP, Pinder DK (2014).The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo.Cochrane systematic review finding Epley maneuver to be safe and effective for posterior canal BPPV.

The clinical practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) recommends the Epley maneuver as first-line treatment for posterior canal BPPV 1Ref 1Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).AAO-HNS recommendation of Epley maneuver as first-line treatment for posterior canal BPPV; support for patient self-treatment with appropriate instruction; watchful waiting as an alternative.

The basic steps for the posterior-canal Epley maneuver (right side as example):

1. Sit on a bed with your legs extended in front of you. Turn your head 45 degrees to the right. 2. Lie back quickly so your head is hanging off the edge of the bed at about a 30-degree angle. Hold 30 seconds (or until dizziness settles). 3. Turn your head 90 degrees to the left (now facing 45 degrees to the left). Hold 30 seconds. 4. Roll your body onto your left side while keeping your head in the same position relative to your body (you end up looking at the floor). Hold 30 seconds. 5. Slowly return to sitting while keeping your head turned to the left, then straighten.

For left-side BPPV, all directions are mirrored. If you are unsure which side is affected, a clinician can perform the Dix-Hallpike test to confirm.

Is it safe to do the Epley maneuver at home?

For most people with uncomplicated BPPV, home repositioning is safe once a clinician has confirmed the diagnosis and taught the maneuver in person. The AAO-HNS guideline supports patient self-treatment with appropriate instruction 1Ref 1Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).AAO-HNS recommendation of Epley maneuver as first-line treatment for posterior canal BPPV; support for patient self-treatment with appropriate instruction; watchful waiting as an alternative.

A few caveats:

• The maneuver is not appropriate if you have neck or back problems that make these positions painful or unsafe
• If the maneuver does not relieve symptoms after two to three attempts, see a clinician — you may have a less common canal involved (horizontal or anterior canal BPPV), which requires a different technique
• Symptoms that are atypical — vertigo that is constant rather than brief, or accompanied by neurological symptoms — warrant in-person evaluation before attempting self-treatment

What if the Epley maneuver does not work?

Several alternatives exist:

Other repositioning maneuvers. Horizontal canal BPPV responds to the Barbecue roll (log roll) or Lempert maneuver. An ENT specialist or vestibular physiotherapist can identify which maneuver is right for your canal involvement.

Vestibular rehabilitation. A physical therapist or audiologist trained in vestibular rehab can provide supervised exercises (including Brandt-Daroff exercises) for recurrent or stubborn BPPV, and address any residual unsteadiness.

Observation. BPPV sometimes resolves on its own. The guideline supports watchful waiting with activity modification as an initial option for mild cases 1Ref 1Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).AAO-HNS recommendation of Epley maneuver as first-line treatment for posterior canal BPPV; support for patient self-treatment with appropriate instruction; watchful waiting as an alternative.

Medication. Vestibular suppressants (such as meclizine) reduce nausea during an episode but do not reposition the crystals and are generally not recommended as primary treatment for BPPV.

If you have multiple recurrences, evaluation by an ENT specialist (otolaryngologist) is worthwhile to rule out Meniere's disease or other inner ear conditions 3Ref 3Basura GJ, Adams ME, Monfared A, Schwartz SR, Antonelli PJ, Burkard R, et al. (2020).Clinical Practice Guideline: Ménière's Disease.Differentiation of BPPV from Meniere's disease and need for specialist evaluation with recurrent vertigo.