Epley Maneuver for Vertigo: Step-by-Step Guide

What is BPPV and why does it cause vertigo?

Benign paroxysmal positional vertigo (BPPV) is the most common cause of episodic vertigo. It occurs when tiny calcium carbonate crystals (otoconia) that normally sit in a specific part of the inner ear (the utricle) become dislodged and migrate into one of the fluid-filled semicircular canals.

When the head moves, these loose crystals shift and stimulate the canal incorrectly, sending a false motion signal to the brain. The result is a brief but intense spinning sensation, typically lasting 20 to 60 seconds, triggered by specific head movements — rolling over in bed, looking up, or bending forward 2Ref 2Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).BPPV diagnosis, canalith repositioning recommendation, vestibular rehabilitation referral for persistent cases, and when specialist referral is appropriate.

BPPV is called 'benign' because it is not dangerous and resolves in most cases, but the vertigo it causes can be disorienting and disruptive. It is the leading cause of vertigo in adults who seek care 2Ref 2Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).BPPV diagnosis, canalith repositioning recommendation, vestibular rehabilitation referral for persistent cases, and when specialist referral is appropriate.

How does the Epley maneuver work?

The Epley maneuver — also called canalith repositioning — works by guiding the displaced crystals out of the affected semicircular canal and back into the utricle, where they no longer interfere with balance signals. This is done by moving the head through a specific sequence of positions, using gravity to move the crystals through the canal.

A Cochrane systematic review found that the Epley maneuver is significantly more effective than control (no treatment or a sham maneuver) in resolving BPPV symptoms, with most benefit within the first one to two weeks 1Ref 1Hilton MP, Pinder DK (2014).The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo.Effectiveness of the Epley maneuver vs. control in resolving BPPV symptoms. The AAO-HNS clinical practice guideline strongly recommends offering canalith repositioning for posterior canal BPPV, the most common type 2Ref 2Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).BPPV diagnosis, canalith repositioning recommendation, vestibular rehabilitation referral for persistent cases, and when specialist referral is appropriate.

How to perform the Epley maneuver at home (for posterior canal BPPV)

These steps address the most common type of BPPV — involving the posterior semicircular canal. Before attempting this at home, a clinician should have confirmed the diagnosis and identified which ear is affected using the Dix-Hallpike test.

Step 1: Sit upright on a bed with a pillow positioned so that when you lie back, it will be under your shoulders (not your head). Turn your head 45 degrees toward the affected ear.

Step 2: Quickly lie back so your head hangs off the edge of the pillow at roughly 45 degrees below horizontal. Your head remains turned 45 degrees toward the affected side. Hold this position for 30 to 60 seconds — you may feel vertigo during this time, which is expected.

Step 3: Without lifting your head, rotate it 90 degrees to the other side (so it is now turned 45 degrees away from the originally affected ear). Hold for 30 to 60 seconds.

Step 4: Roll your body in the direction your face is now pointing (onto your side) while keeping your head and body aligned, so you end up on your side with your face angled toward the floor. Hold for 30 to 60 seconds.

Step 5: Sit up slowly from this position.

Most clinicians recommend performing the maneuver one to three times in a session and repeating it daily until vertigo-free for 24 hours.

How well does the Epley maneuver work?

The Cochrane review of the Epley maneuver found it substantially better than placebo at resolving BPPV, with a majority of patients achieving symptom resolution within one to a few treatment sessions 1Ref 1Hilton MP, Pinder DK (2014).The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo.Effectiveness of the Epley maneuver vs. control in resolving BPPV symptoms.

The maneuver is less effective when: - The affected ear is incorrectly identified - A less common type of BPPV is present (horizontal or anterior canal BPPV, which require different maneuvers) - The technique is not performed precisely

This is one of the main reasons a clinician should confirm BPPV and demonstrate the maneuver before you try it at home. If the Epley maneuver fails after several attempts, the AAO-HNS guideline recommends referral to a vestibular physical therapist, who can evaluate canal involvement and adapt the repositioning strategy 2Ref 2Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).BPPV diagnosis, canalith repositioning recommendation, vestibular rehabilitation referral for persistent cases, and when specialist referral is appropriate.

Are there other exercises for BPPV?

The Brandt-Daroff exercises are an alternative home exercise that some clinicians recommend when the Epley maneuver cannot be performed or when BPPV is not fully resolving. They involve repeatedly moving from sitting to side-lying positions. They are thought to work by habituating the brain to the abnormal signals from the displaced crystals rather than by mechanically repositioning them, and they tend to require more repetitions over a longer period.

For horizontal canal BPPV, a different maneuver called the log roll (Barbeque roll) is used. Your clinician can identify which type is present using a modified diagnostic test and guide you on which maneuver is appropriate.

Vestibular rehabilitation therapy (VRT) with a physical therapist who specializes in vestibular disorders is an effective option for people with persistent or atypical BPPV 3Ref 3McDonnell MN, Hillier SL (2015).Vestibular rehabilitation for unilateral peripheral vestibular dysfunction.Vestibular rehabilitation therapy is effective for reducing dizziness and improving function in peripheral vestibular disorders including BPPV when canalith repositioning is insufficient. A Cochrane review found VRT reduces dizziness and improves function in people with peripheral vestibular conditions who do not respond to repositioning maneuvers alone 3Ref 3McDonnell MN, Hillier SL (2015).Vestibular rehabilitation for unilateral peripheral vestibular dysfunction.Vestibular rehabilitation therapy is effective for reducing dizziness and improving function in peripheral vestibular disorders including BPPV when canalith repositioning is insufficient.

When should I see a clinician rather than trying the Epley maneuver at home?

Do not attempt the Epley maneuver without a clinician assessment first if:

• You have not been diagnosed with BPPV — vertigo has many causes, and some require different treatment
• You have had a recent neck injury, significant neck pain, or conditions that limit neck movement
• The vertigo is continuous (BPPV typically causes brief episodes, not constant spinning)
• You have neurological symptoms alongside the vertigo — double vision, weakness, difficulty speaking, or severe headache
• You have severe dizziness that prevents you from safely moving through the head positions

A primary care clinician or ENT specialist can perform the Dix-Hallpike test to confirm BPPV, identify the affected ear and canal, and either treat it in the office or demonstrate the correct home technique.