Indication
- Treats posterior canal BPPV that has been confirmed on the Dix–Hallpike manoeuvre, which also identifies the affected (lower) ear.
- The manoeuvre is performed toward the affected side first — i.e. start with the head turned to the ear that was positive.
Cautions
- Same relative cautions as Dix–Hallpike: significant cervical spine disease/instability, recent neck injury or surgery, severe carotid/vertebrobasilar disease, unstable cardiac disease, recent retinal detachment.
- Warn the patient that the manoeuvre will provoke vertigo and often nausea in each position; support the head throughout and have a receiver to hand.
Technique — for a positive right ear
Hold each position for about 30 seconds, or until any provoked nystagmus/vertigo settles. For a left-sided BPPV, mirror every direction.
Start sitting, head turned 45° to the right
Patient sitting lengthways on the couch, positioned so the head can extend beyond the top edge. Turn the head 45° toward the affected (right) ear.
Lie back into the Dix–Hallpike position
Keeping the 45° right rotation, lower the patient briskly to supine with the head extended ~20–30° below horizontal, right ear down. Hold ~30 seconds.
Rotate the head 90° to the left
Without lifting the head, turn it 90° so it is now 45° toward the left (unaffected) side, keeping the neck extended. Hold ~30 seconds.
Roll onto the left side, head a further 90°
Ask the patient to roll onto their left shoulder as you continue turning the head another 90°, so they end up looking down toward the floor (face roughly 45° below horizontal). Hold ~30 seconds.
Sit back up
Keeping the head turned, bring the patient up to sitting, then return the head to the midline with the chin tucked slightly down. A short-lived unsteadiness on sitting is common.
Effectiveness
- A single Epley resolves symptoms in roughly 70–80% of posterior canal BPPV; repeating the cycle in the same visit increases success.
- It is the recommended first-line treatment for posterior canal BPPV and is more effective than medication or watchful waiting.
- Vestibular sedatives (e.g. prochlorperazine) do not treat BPPV and are not a substitute for repositioning; if anything they can mask symptoms and impair recovery.
Aftercare & recurrence
- Warn of transient unsteadiness or mild residual dizziness for a day or two.
- Post-manoeuvre movement restrictions are not routinely needed — the older advice to stay upright for 24–48 hours or sleep propped up has not been shown to meaningfully improve outcomes.
- BPPV commonly recurs; teach patients that the manoeuvre can be repeated, and consider self-treatment options (home Epley or Brandt–Daroff exercises) for recurrent cases.
- Safety-net: seek review if new neurological symptoms, hearing loss, or continuous (rather than brief, positional) vertigo develop — these are not BPPV.
Supervision pointers
Generic ED skills entrustment levels — not a named curriculum DOPS:
| 1 | Observed only — explains the rationale and that diagnosis precedes treatment. |
| 2a | Performs the sequence with supervisor present, treating the correct side. |
| 2b | Confirms success with a repeat Dix–Hallpike and gives appropriate advice. |
| 3 | Indirect supervision; manages recurrence and recognises when it is not BPPV. |
| 4 | Independent; teaches the technique and home exercises. |
References
- Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg 2017;156(3_suppl):S1–S47.
- Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2014;(12):CD003162.
- NICE CKS — Benign paroxysmal positional vertigo.