BPPV Exercises: Epley Maneuver and Repositioning Techniques

Benign Paroxysmal Positional Vertigo (BPPV) causes intense, brief spinning episodes triggered by head movements. The good news: it's highly treatable with specific repositioning maneuvers that move displaced crystals out of your semicircular canals. Learn the Epley maneuver and other techniques to cure your BPPV at home.

Understanding BPPV

BPPV occurs when tiny calcium carbonate crystals (otoconia) become dislodged from the utricle and float into the semicircular canals of the inner ear. When you move your head, these crystals move and send false signals to your brain, causing vertigo.

Characteristics:

• Brief episodes (usually under 1 minute)
• Triggered by head position changes
• Intense spinning sensation
• May cause nausea
• Often worse in the morning

Common triggers:

• Rolling over in bed
• Looking up
• Bending forward
• Tilting head back

Which canal is affected:

• Posterior canal: Most common (80-90%)
• Horizontal (lateral) canal: 10-15%
• Anterior canal: Rare

Identifying Your Affected Side

Before treatment, identify which ear is affected:

The Dix-Hallpike Test:

1. Sit on bed, legs extended
2. Turn head 45 degrees to one side
3. Quickly lie back with head hanging slightly over edge
4. Wait 30-60 seconds
5. Watch for vertigo and nystagmus (eye movements)
6. Sit up slowly
7. Repeat on other side

Positive test: The side that triggers vertigo is the affected side. For posterior canal BPPV, nystagmus will be upbeating and torsional.

Tip: Have someone watch your eyes, or record yourself.

The Epley Maneuver (Posterior Canal)

The Epley maneuver is 80-90% effective for posterior canal BPPV.

Step-by-Step Instructions

For RIGHT ear BPPV:

1. Start position: Sit on bed with legs extended, pillow behind you positioned to be under shoulders when lying back

2. Position 1: Turn head 45 degrees to the RIGHT (toward affected ear)

3. Position 2: Quickly lie back, keeping head turned. Head should hang slightly over pillow edge, tilted back about 20 degrees. Stay here 30-60 seconds (until vertigo stops)

4. Position 3: Turn head 90 degrees to the LEFT (now looking 45 degrees left). Keep head tilted back. Stay 30-60 seconds

5. Position 4: Roll onto left side while turning head to look at floor (nose pointing down). Stay 30-60 seconds

6. Position 5: Keeping head turned down, slowly sit up sideways

For LEFT ear BPPV: Mirror these instructions (start looking left, roll onto right side).

After the Epley Maneuver

Old recommendations (no longer required):

• Don't lie flat for 48 hours
• Sleep sitting up
• Wear a cervical collar

Current evidence: These restrictions are unnecessary. However, some clinicians recommend:

• Wait 10 minutes before standing
• Avoid quick head movements for rest of day
• Sleep on unaffected side the first night

Repeating the Maneuver

• May need 2-3 treatments
• Wait 24 hours between attempts
• If no improvement after 3-4 tries, see a vestibular specialist

The Semont Maneuver (Alternative for Posterior Canal)

Also effective for posterior canal BPPV, especially if Epley is difficult.

For RIGHT ear BPPV:

1. Sit on edge of bed
2. Turn head 45 degrees to the LEFT (away from affected ear)
3. Quickly drop sideways to the RIGHT, lying on right side, nose pointing up
4. Stay 30-60 seconds
5. Quickly swing through sitting to lying on LEFT side, nose pointing down
6. Stay 30-60 seconds
7. Slowly sit up

For LEFT ear BPPV: Mirror these instructions.

Brandt-Daroff Exercises (Habituation)

These exercises help when repositioning maneuvers don't fully resolve symptoms, or for recurrent BPPV.

Instructions:

1. Sit on edge of bed
2. Turn head 45 degrees to the right
3. Quickly lie down on LEFT side (nose pointing slightly up)
4. Stay 30 seconds or until vertigo stops
5. Sit up, stay 30 seconds
6. Turn head 45 degrees to the left
7. Quickly lie down on RIGHT side
8. Stay 30 seconds
9. Sit up

Frequency:

• 5 repetitions per session
• 3 sessions per day
• For 2 weeks or until symptom-free for 2 consecutive days

Horizontal (Lateral) Canal BPPV

Horizontal canal BPPV causes vertigo when turning head side to side while lying down.

BBQ Roll (Lempert Maneuver)

For RIGHT horizontal canal BPPV:

1. Lie on back, head straight
2. Turn head 90 degrees to the LEFT (away from affected ear)
3. Stay 30-60 seconds
4. Roll body to face left, head still turned left
5. Stay 30-60 seconds
6. Continue rolling: now face down, head turned left
7. Stay 30-60 seconds
8. Continue rolling: now on right side, head turned left
9. Stay 30-60 seconds
10. Slowly sit up

Essentially, you "roll" 360 degrees away from the affected ear.

Gufoni Maneuver (Horizontal Canal)

For geotropic horizontal BPPV (nystagmus beats toward ground):

1. Sit on edge of bed
2. Quickly drop sideways onto UNAFFECTED side
3. Stay 1-2 minutes
4. Quickly turn head 45 degrees DOWN toward floor
5. Stay 2 minutes
6. Slowly sit up

When to Seek Professional Help

See a vestibular specialist if:

• Symptoms don't improve after 3-4 self-treatments
• You can't identify which ear is affected
• Symptoms are atypical (constant vertigo, hearing changes)
• You have neck problems preventing positioning
• Nystagmus doesn't match typical patterns
• You've had head trauma

A trained professional can:

• Accurately diagnose which canal is affected
• Perform maneuvers more precisely
• Identify atypical variants
• Rule out other causes

Tips for Success

Before Treatment

• Have someone assist you
• Keep a basin nearby (nausea possible)
• Remove glasses
• Have water available
• Perform on bed or padded surface

During Treatment

• Move quickly between positions
• Hold each position long enough (30-60 seconds minimum)
• Expect vertigo during the maneuver (means crystals are moving)
• Don't give up if vertigo is intense

After Treatment

• Rest for 10-15 minutes
• Move head slowly for the rest of the day
• Be cautious with triggers for 24-48 hours
• Sleep with head slightly elevated first night (optional)

Prevention of Recurrence

BPPV recurs in 15-50% of people. Reduce risk:

Vitamin D: Low vitamin D is associated with recurrent BPPV. Get levels checked and supplement if deficient.

Sleep position: Some evidence suggests sleeping on the unaffected side reduces recurrence.

Head trauma: Avoid activities with risk of head impact.

Regular vestibular exercise: Balance exercises may reduce recurrence.

Vestibular Exercises for Recovery

After repositioning, residual dizziness is common. These exercises help:

Gaze Stabilization

1. Hold a target (business card with letter) at arm's length
2. Move head side to side while keeping eyes fixed on target
3. Start slowly, increase speed
4. 1 minute, 3 times daily
5. Progress to up-down movements

Balance Exercises

Standing balance:

1. Stand with feet together
2. Hold 30 seconds
3. Progress: eyes closed, one foot in front of other, single leg

Walking exercises:

1. Walk in straight line
2. Walk turning head side to side
3. Walk with eyes closed (with spotter)

What BPPV Is NOT

BPPV is often confused with:

• Meniere's disease: Hours of vertigo with hearing changes
• Vestibular neuritis: Days of constant vertigo
• Stroke: Sudden vertigo with other neurological symptoms
• Anxiety dizziness: Not triggered by position changes

If symptoms don't match BPPV pattern, seek medical evaluation.

The Bottom Line

BPPV is the most common cause of vertigo—and the most treatable. The Epley maneuver works for most people with posterior canal BPPV. Key points:

1. Identify the affected ear first
2. Perform the Epley correctly - Hold positions long enough
3. Repeat if needed - May take 2-3 treatments
4. Seek help if unsuccessful - Professionals can treat atypical cases
5. Prevent recurrence - Check vitamin D, maintain balance

That intense spinning can be cured with a simple repositioning maneuver. Don't suffer with BPPV—learn the Epley and take control of your vertigo.