The Epley Maneuver for BPPV Particle Repositioning
Many people with dizziness or vertigo have heard of the “Epley maneuver” as a treatment.
The Epley maneuver is used to reposition BPPV crystals.
It is the first procedure of its kind, published in the early 90’s by the late US-based physician named, John Epley. Since then, many healthcare providers and vertigo researchers around the world have developed a whole catalog of additional “particle repositioning maneuvers.”
In this blog, I discuss the top five reasons why the Epley maneuver may not be effective for BPPV treatment.
Incorrect Technique
First of all, many providers who are “dabbling” in vertigo care perform the maneuver incorrectly.
The Epley maneuver, the modified Epley, and all the particle repositioning maneuvers for BPPV require very precise, technically accurate performance to be effective. Unless the provider has studied the technique to reproduce precision and accuracy, they may be performing the Epley maneuver incorrectly.
In teaching this maneuver and other particle repositioning treatments to other providers, I have discovered certain predictable errors that are made by beginners. Those errors will reduce the effectiveness of the treatment.
Treating the Wrong Ear
Secondly, you have to treat the correct ear in order for the Epley maneuver to work.
The first step to effectively treating BPPV is to determine which ear is involved.
The options are right ear, left ear, or both ears. This can be determined through BPPV testing by a skilled provider.
I have been surprised how many times I have met a patient who described previous treatments to the “uninvolved ear” that obviously did not help at all, and in fact made them feel worse.
Treating the Wrong Semi-Circular Canal
There are three semi-circular canals in each inner ear. You must determine the canal that needs treatment.
The Epley maneuver is designed for the posterior canal.
If BPPV crystals are free-floating in the horizontal or anterior canal, then the Epley maneuver will not likely resolve the complaint.
Those other inner ear canals require different treatments that have been developed after the Epley maneuver was first published.
BPPV Crystals are Stuck
The BPPV particles can get stuck.
The Epley maneuver makes an assumption that the BPPV crystals are free-floating in the posterior canal of the ear being treated. However, there is a possibility that the BPPV crystals or debris can adhere to the sensory apparatus within the semi-circular inner ear canal called the “cupula.”
This is a type of BPPV called “cupulolithiasis,” as opposed to the more common “canalithiasis” with the free-floating crystals.
Cupulolithiasis is rare. In my experience treating literally thousands of people with BPPV, I have only found six people so far who have BPPV crystals stuck on their cupula.
It is possible to break the BPPV crystals off the cupula and resolve the problem, but starting with the Epley maneuver will not be effective in this case.
It’s not BPPV
The fifth reason that the Epley maneuver may not work is that you may not be dealing with BPPV.
There are other conditions that can mimic BPPV, even causing positional nystagmus and positional vertigo symptoms.
The five reasons I have listed above illustrate the importance of finding a skilled Vestibular provider to assess and treat your symptoms of dizziness, vertigo, and imbalance.
By doing this, the proper diagnosis can be assigned and the necessary care can be delivered effectively. You can get your life back!
Disclaimer
This blog is provided for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that I might see and do not describe the circumstances of a specific individual.
great article, and very helpful.
Important reasons to seek help from an experienced professional .
Nice article, and highlights some additional issues I was not aware of in self diagnosing and treating my own BPPV for a second time, but then experiencing no initial change in symptoms..
I have a cochlear implant. I’m hearing impaired in my other ear. Epley Maneuvers are not working on me anymore.
Vertigo and dizziness contribute to falling. Vertigo has identifiable cause regarding the inner ear. What causes the dizziness? How can it be treated? Many falls are experienced from one or both conditions while wearing a helmet and using a four wheel walker.
Hi Will,
Yes, vertigo and dizziness definitely contribute to falling.
I have written this blog about what causes dizziness in the body.
There are many treatments for the various root causes of dizziness and vertigo.
On this page, I describe some of the treatments that are available today.
The key is to find a skilled provider to work with.
Sincerely,
Kim Bell, DPT
I was diagnosed with bppv right ear posterial canal ,have had Epley maneuvers and and dix halpike none helped ,I have balance issues with a back neck I can’t bend over and my eyes have something to do with it also
Hi Leanne,
It sounds like you have a situation that requires further investigation by skilled Vestibular provider.
You can use this blog to find a Vertigo Doctor in your area.
This blog on what to do when vertigo exercises don’t help may also be useful.
In this area of care, the most important thing is the results. I wrote this blog with three questions to ask when choosing a healthcare provider.
If your results are not satisfactory, then you may want to seek another opinion.
This blog and this blog outline the important reasons to seek skilled care without delay.
If you ever want to venture to San Diego, I would be happy to work with you in person.
I wish you all the best for a full recovery!
Sincerely,
Kim Bell, DPT
I have vertigo issues also. Trying the exercises with no effect.
It seems to be triggered with pain in my neck back/skull.
Please let me know what you found to help.
Dan
I am Menieres diagnosed. I had BPPV like spins when I would turn into my “bad” ear. The only treatment that helped to relieve my symptoms was treating it as a jaw\muscular issue. I know so many others who have been helped this way. I haven’t had vertigo for 32 months now and all the other miserable symptoms have gone too. Only tinnitus remains but livable. I think the medical community is doing a tremendous disservice by continually looking solely at these symptoms as vestibular or neuro. Look at the way we live. Our necks, heads , backs upper arms, front of chest are in positions day in an out that they are not meant to be in. When you turn into a muscle in spasm it causes spins. If you have them in spasm continually the messages delivered through the ear gets screwed up. Please, this needs to be considered and tested so that people stop suffering and get their lives back.
Hi Beth,
What a great story! I am so happy to hear that you haven’t had vertigo for 32 months now!
Perhaps soon, you will be counting in years instead of months?!
I completely agree with you about the disservice to people suffering with dizziness and vertigo by only treating it as a neurological or vestibular problem.
That is why I developed my own comprehensive, unique methodology of evaluating and treating these complaints, called “The Bell Method.”
With my patients, I perform a comprehensive, multi-system analysis to determine the root cause of their symptoms.
Sadly, many patients spend months to years going from one specialist to the next without ever determining the root cause of their problems. A lot of providers are subject to tunnel vision.
I am completely with you on the importance of considering the neck and jaw muscles, bones, and fascia in determining any musculoskeletal contribution to the cause of dizziness, vertigo, balance problems, and tinnitus.
Thank you for adding your input to this important conversation and sharing your success story!
With gratitude,
Kim Bell, DPT
Hi very interesting I have been searching for yrs as to y I have vertigo bought on by stress at times but I’m desperate for approx 10 yrs ago I had my first episode of complete muscle failure my witness was mum my daughter in her wheelchair and at that time my dad when he was still with us
I’m not there I remember just the end or beginning or not at all but I hallucinate slurred speech but continually falling my dr said it was long term trauma
We questioned it forgot about it just the same dad bouts of vertigo I got labyrinthitis yrs ago from flood water viral
But it’s happened 8 times putting me in hospital big scar on face waiting for surgery for pins of foot I destroyed while falling all over things for up to 30 hrs
But after the 5th time I was referred to public neurologist before COVID-19 began now it’s 8 times both my eldest daughter and son on 2 occasions saw me coming around I remember them all telling me to sit down or drunk legs I’m not ment to be driving I spent 11 nights in hospital when I did my foot and knocked my front teeth out but was discharged on crutches after some tests and scans all clear I don’t remember the ambulance or being admitted I was confused at first anyway has anyone heard of such a thing
I do have ptsd for very good reason but I’m 55 and I’m used to stress and vertigo plus other dreppeessive disorder all of those and long term trauma only should happen once in a lifetime maybe 2 but not 8 do you think it could be all related
Thankyou
Hi Jo,
Wow that is scary! You could work with your doctor to assess you for vasovagal syncope which can be triggered by severe emotional stress.
If you have not already consulted with a Vestibular Physical Therapist or Oto-Neurologist or Neurotologist, then one or more of those three options could be helpful in analyzing the root cause(s) of your situation.
You can organize your story by following the outline I suggest in this blog.
This blog is about the link between PTSD and vertigo.
I hope you can find answers and get relief soon!
Sincerely,
Kim Bell, DPT
I am located in Boston. I have been diagnosed with BPPV. I treated with PT at MGH for my right ear; and with only one Epley Maneuver treatment it was gone. A couple of months later, it came back but to my left ear. It is horrible. I have had two treatments of 2 adjustments each with the Epley Maneuver for my left ear. It has not worked and the Epley is really making me sick.
Hi Beth,
I know you made this comment almost two years ago, but I wanted to see if maybe you see this reply. I noticed you mentioned receiving jaw/muscular treatment for your dizziness. What kind of treatment did your doctor do for that and were you having bad jaw and muscle pain? I’ve seen so many different specialists who said I don’t have an inner ear problem. I also went to a TMJ specialist after researching everything else. He had me wear an appliance for almost a year because he thought that would alleviate the dizziness, but it didn’t. So, I’m wondering what you had done.
Thank you,
Sherry
I’m very surprised to hear you have only seen 4 cases of cupulolithiasis. We see it on a fairly regular basis in our practice in both the horizontal and posterior canals.
Hi Margaret,
Thank you for sharing your clinical experience treating patients at your PT clinic in Pennsylvania, USA.
In fact, I just had two more recent patients with cupulolithiasis, so my total is now up to 6. (I will go ahead and update the blog now to reflect that number.)
Six is still a very low number in a sample size of somewhere around 5,000 cases of BPPV that I have treated to date.
You may be also interested in reading this webpage by Dr. Timothy Hain, MD who reports only 8 confirmed cases of cupulolithiasis in his practice database of 25,000 patients as of 2019.
I think your point illustrates the importance of avoiding the use of anecdotal evidence to drive our understanding of epidemiological trends and population data.
Although we are treating a similar population, we have clearly had different patients come across our path.
The good news is that they have arrived at the right place and the right time to receive our skilled Vestibular care!
It is a pleasure to be out here in the trenches alongside you changing lives, one at at time!
Warmest regards,
Kim Bell, DPT
” It is possible to break the BPPV crystals off the cupula and resolve the problem, but starting with the Epley maneuver will not be effective in this case. ”
What should be used to break them free?
Hi Berat,
There are a few treatment techniques that can be used to break them free.
I cannot advise you which would be best, because each case is different.
My suggestion is to find a skilled Vestibular Provider to evaluate the situation in person, then recommend the most appropriate treatment.
You can use this link to find a Vertigo Doctor in your Area.
Best wishes,
Kim Bell, DPT
Have you experienced a patient having downbeating nystagmus without having anterior canal BPPV, but instead having multiple other canals affected by crystals?
If so , can you give me an example?
I have downbeating nystagmus/slightly horizontal left due central reasons probably, but i also have BPPV.
When put in Dix-hallpike position right side my nystagmus ( downbeating ) increases very, but left on the left side it decreases even tho it`s still there. I go to one of the best vestibular therapist in my country, but even he struggles a little because of the intensity of the DBN.
I have been treated on the left anterior, right anterior with no relevant results.
I got treated in the horizonal-right canal with huge results, but the DBN still remains even tho it has decreased sometimes it spikes. I got a little bit of horizontal- nystagmus left that indicates that the right-horiszontal canal is not clear of crystals yet.
My question really is if it is possible that the DBN can come from having crystals in the posterior canal also or maybe both posterior canals?
Sorry for this long comment, but my case is really difficult so i was hoping you maybe have some answers that can help.
Hi Berat,
I am so happy to hear that you are working with a highly skilled Vestibular Physical Therapist!
The answer to your question is yes, I am very familiar with all types of nystagmus presentations, both typical and atypical.
If you would like to consult with me on your individual case, I invite you to travel to San Diego so I can evaluate you in person, establish a therapist-patient relationship with you, and subsequently offer individual medical advice regarding the details you described.
You can learn more about my services, along with answers to frequently asked questions here.
All my best,
Kim Bell, DPT
Dizziness when bend over or move my head downward. Is it related to BPPV or not ?
Hi Ali,
That specific motion is certainly on my list of BPPV symptoms. Check out this blog to learn more.
You can use this blog to find a provider in your area.
I recommend an exam by a vestibular physical therapist to determine if you have BPPV or something else going on.
Best wishes,
Kim Bell, DPT
What could it be if it’s not BPPV?
My ears pop when I swallow and feel slightly painful at times. The physical therapist has done the epley but I don’t get the eye flickering but do feel nausea.
Hi James,
You may want to check out these additional resources:
Symptomatic BPPV
More on Symptomatic BPPV
Eustachian Tube
Best wishes,
Kim Bell, DPT
I recently sufffered my worst episode of vertigo to date. I was diagnosed by my Primary Care doc 15 years ago, when I was in my early 40s. He had performed one quick check, laid me back with my head hanging over exam table, and looking at my eyes. By the time he got the words out “try not to close your eyes” they were closed, so thinking back, I can’t imagine he witnessed much nystagmus, but he stated it was BPPV, “not big deal, no need to see a specialist, it should go away quickly, not worries driving….etc.” I accepted that, and have just dealt with it over the years, by attempting exercises I’ve found online. I’ve had long stretches of no episodes, but I’ve noticed that when they do occur they’re much worse than previous ones. However, it has seemed like performing the exercises really helped. This time I thought I was being clever, and proactive attempting to get a jump on lessening the symptoms, when I was experiencing mild symptoms; BUT the first rep of the exercise created such severe nystagmus I thought I felt my own eyes about to jump out of my head, and had to close them immediately (which if I understand things correctly defeats the purpose of the exercises…) and of course became severely nauseated. I kept thinking if I’d been able to throw up, maybe it would have been better, but I didn’t, and I became so terrified of how awful it felt, I laid on one side in the bed, afraid to move.
Everytime I’d reach out on the other side for something on the night stand it would be unbearable. I’d muster the courage to attempt the somersault maneuver, (because dang – I can’t just lay in the bed for god knows how long!?!?) Each attempt resulted in my feeling like I’d never be able to open my eyes again. I did this a couple of times with high hopes that I’d miracuoulously feel better, Didn’t happen. This was Sunday evening. I didn’t eat anything but saltines, and drank diet ginger ale until late Tuesday. I attempted some soup but could only stomach a bite or two. I managed to get an appointment with a new ENT in town on Tuesday. By the time he educated me on all the details of the different kinds of vertigo, etc… and performed the Epley, when he turned my head to the left, (which was the side that was the worst) Nothing! Apparently I’m like every car I’ve ever owned…having symptoms until I’m taken to the mechanic, and then there’s no noise. I was so flabbergasted, and disappointed. How am I suppoed to get a real accurate diagnosis, if the worst of the symptoms calms down by the time I can see a doc?? He was able to see a mild nystagmus on the right, but what the heck?!?! I DID feel much better after the appointment, but i’m not sure if it was a result of his treatment, or my just being up and moving, and sitting up for longer than I had the past few days. Anyway – I’m not satisfied with letting this drop, and I’m wondering are there any diagnostics out that can determine the side/canal, etc… without my attempting to run to the docs office at a time when I can barely crawl to the bathroom?? Apologies for the length of this message, but I really want to get some kind of real accurate diagnosis, and help with this. I beleive he’s leaning towards it being the Neuropathia vestibularis or vestibular neuritis, rather than BPPV, because he’s prescribed me an antibiotic (believing there’s an ear infection) AND Prednisone because he advised that even if the infection is cleared, there would be inflammation that will just continue to cause me issues. Any thoughts on this would be greatly appreciated.
Hi Deana,
I love your analogy about the car mechanic! So true!
First of all, I do not recommend for people to attempt exercises on their own unless they have been instructed by a Vestibular Physical therapist.
There are just too many things that can go wrong, and only really one way it can go right. You can easily see the odds are not in your favor without proper instruction!
I discuss this concept in more detail in this blog.
One consideration is the time of day that you saw the doctor. Symptoms usually dissipate later in the afternoon.
A morning appointment is best to pick up any remaining BPPV, if your symptoms are more mild.
Another consideration is that your self-treatment may have been successful. I am not sure if you considered that possibility.
You can still get sick during or after a successful BPPV treatment. That is not uncommon.
If you feel that you would like to seek another opinion, I suggest the following.
The type of doctor who specializes in dizziness is called either an Otoneurologist or a Neurotologist. Those are sub-specialties within Neurology and ENT medicine.
You can use this blog to find a Vestibular provider in your area.
A Vestibular Physical Therapist will probably also be a good resource for you now or in the future. Those are physical therapists with special training in treating BPPV and vestibular neuritis.
This blog discusses recovery from Vestibular Neuritis.
This blog is about what to do when vertigo exercises don’t help.
If you have not already found this blog, I share some Home Remedies that may help you while you are trying to figure out your next steps.
Of course, I suggest that you take all medications as prescribed by your doctor.
I hope the information I shared was helpful.
I hope you feel better soon!
Best wishes,
Dr. Kim Bell, DPT
I have been having symptoms of vertigo that are just getting worse. Afraid to try Epely manuver for fear of it getting worse. Where do I start for help? An ENT doctor? This has been going on for three months. Please help!
Hi Lorraine,
I am sorry for what you are going through! It sounds like you need professional vertigo care.
You can use this article to find a Vestibular Doctor or Vestibular Physical Therapist in your area.
This article has Vertigo Home Remedies that may help you while you are waiting to get treated.
I hope that helps!
Best wishes,
Kim Bell, DPT
Hi – great informative article – you have a new reader from the UK.
I have been diagnosed with BPPV following a vertigo episode 6 days ago
My ENT specialist did the Pike-Hall manoeuvre on me to dyer one which “SIDE” is the problematic side, triggering my symptoms, however, I emphasise the word “SIDE” because he said that while these types of tests can determine which “SIDE” is triggering, it doesn’t necessarily establish which “EAR” is the problematic one.
Is he incorrect in his assertion then as it runs counter to the remarks in your article here about “treating the wrong ear”.
Hi Niki,
Yes I agree with your ENT because there are “atypical” types of BPPV. In some of these atypical cases, the symptoms show up on one side, but the involved ear is actually the opposite ear.
The statement that I made still holds true that if you “treat the wrong ear,” then the maneuver will not work.
I hope that helps!
Best wishes,
Kim Bell, DPT
The experience is frightening due to excessive imbalance during the act and it may not suit all.
My wife has hydrocephalus normal pressure and a shunt fitted she has developed or already had we dont know Vertigo we have been to specialists who administered the epleys maneaver but after 3 sessions it only made the balance and walking worse ,prior to her developing hydrocephalus she was an international stadard swimmer and now cannot swim any advice.
Hi Geoffrey,
This represents a complicated situation. I am sorry to hear what you are going through!
It is important to find a Neurologist who is skilled and knowledgable at managing normal pressure hydropcephalus.
Also, you may need to find a Vestibular physical therapist using this blog.
I wish you two all the best! She is lucky to have such a supportive and caring husband.
Best wishes,
Kim Bell, DPT
I have been having on and off vertigo for the past three years. I visited ENT who recommended me to do Epley Maneuver at home if vertigo attacks again. The past weekend I had a vertigo attack and I find out myself both my left and right side are affected by BPPV – I feel dizzy if I turn my head to the left and vice versa, also bend down or high up my head.
I am confused how to perform correct Epley Maneuver. If I do the right side AFTER doing my left side consecutively in a session, will the ear crystals roll off its correct position as the left side is fixed. Or should I start doing 3 times on the affected left side for a few days first, wait for a few days to ensure no dizziness for the left turning head, and then, move on to do the affected right side? Most sources do not specify the proper sequence and frequency which worries me to do it wrong. Some even advises to do Epley Maneuver by specialist/doctor only.
Any advice is appreciated!
Hi Raccoon,
If you were able to successfully resolve your vertigo on your own, then I would say “Bravo!”
But it sounds like you have a lot of unanswered questions, resulting in confusion and uncertainty. That is common when people attempt to treat themselves, so my suggestion is to seek a consultation with a Vestibular Physical Therapist.
This article describes the reasons I suggest seeking professional help to resolve vertigo.
I am in alignment with the sources that advise to have this treatment done by a professional. In my experience hearing the stories of many people who have attempted self-treatment, there are so many ways it can go wrong.
You can find a Vestibular provider in your area using this article.
This article has Home Remedies that may help in the meantime.
I suggest you seek professional vertigo care!
Beware of misinformation online. You never know who is posting the content. They do not specify because they may not know!
In addition to my websites, reliable sources include Vestibular.org and Dr. Timothy Hain’s website.
Best wishes,
Kim Bell, DPT
I have suffered with BPPV for around 17 years. Initially it was bad, being sick for days and gradually it became better, I have went months and then years between episodes, that could last a day or two.
This latest episode has lasted 5 months. I went to a balance therapist who could see (from the goggles I wore) that it was my left side that was affected and I had 5 separate Epley manoeuvres. The only thing that improved was that I stopped being sick whilst he was performing them.
I have tried acupuncture (3 sessions so far) which is helping a little but it has not gone away.
The only relief I get is to sleep with 2 pillows, but that in turn doesn’t give me a great nights sleep and also is starting to give me neck pain.
I try during the evening to lie on my bed flat to see if the vertigo is still there and it is…. tonight after trying I just feel really sick.
I am so sick of this now it has taken over my life. Starting to feel I will never be back to normal.
Anyone else had this this long?
I was diagnosed with BPPV in my right ear and referred to a Dr. Of PT with experience in this area. They had me doing the Eply but no improvement, then they had me doing the Brandt/Daroff bit again no improvement. For the Epley after doing the rotations and then sitting up I become extremely hot and nauseous. Similarly for the Brandt/Daroff I became extremely nauseous after the 4th cycle. It usually takes 30-90 minutes to recover from either one.
Not sure if this provides any insight but I’m at a loss and have had this for over 4 months straight. I have to sleep sitting up and can’t turn my head right.
Thanks so much.
I have attacks of BPPV every few years mostly after a dentist visit. My former ENT showed us how to do the Epley and usually within one or two maneuvers it’s corrected. This time we have done five and it brings on the vertigo so intense I almost throw up. Does this mean we are doing the correct ear because it is triggering it? I am not sure how many more times we should try before trying to get into a doctor . It is usually my right ear that’s affected. I haven’t been able to do anything in a week.
Hi Kimberly,
I recommend for you to consult with a vestibular physical therapist, who can answer your individual questions.
There are a lot of possible answers to your question, so I cannot speculate without seeing you in person.
This article may help you find someone local.
This article has home remedies that may help.
This article and this article may help you regarding the connection between vertigo and teeth.
Best wishes,
Kim Bell, DPT
The doctors still can not figure out what is going on with my dizziness. At one point, I was bedridden for a month. I just want these episodes to stop. I have severe migraines including vestibular. Ct Scan and MRI came back normal. I feel like I am in constant motion even when sitting.
The doctors can not even agree as to what is wrong. All I know is that Ativan helps me with the spinning, this happens once a year.
I’m so frustrated and it impacts my quality of life. I feel like it is my ear that is the issue. I went on a flight a long time ago and my eardrum turned inside out…had lots of pressure. The ER doctor said he has never seen anyting like that. I need help
Hi Veronica,
I am sorry to hear what you are dealing with! I will share a few articles that may be helpful.
How to Find a Vertigo Doctor in Your Area
Vertigo Home Remedies that Help
Frustrated by Vertigo: What to do
I hope you find answers and relief soon.
Sincerely,
Kim Bell, DPT