Epley Maneuver at Home: The Ultimate Guide

Every day, many people wonder how to treat paroxysmal vertigo at home. Specifically, how to perform self Epley maneuver, at home?

Does physiotherapy really provide any additional benefits? What are the possible side effects?

As a physical therapist, I address frequently asked questions on this topic. I rely on my experience as a physiotherapist and extensive research in medical studies. All references are provided at the end of the article! There is also a comment section where you can leave your remarks or questions.

Good reading 🙂!

Is there a method to self-treat positional vertigo?

Some non-healthcare professionals may be tempted to perform vestibular rehabilitation tests and maneuvers on their own. You might be searching for a method to self-treat positional vertigo!

Indeed, you can easily find well-made videos on internet that explain the procedure. However, there are a few limitations to attempting these maneuvers on your own:

• Often, you will need a third person to guide the maneuver (unless you have an excellent memory and dexterity).
• It is essential for you to be certain of the diagnosis of positional vertigo, the affected canal, and the side. Additionally, a third person can observe the appearance and nature of any nystagmus.
• If the vertigo persists, it is challenging for you to determine whether it is due to an incorrectly performed maneuver or another reason.
• It can be difficult for you to remember all the steps of the maneuver and execute them correctly on the first try.
• Receiving an individualized session, where a third person listens to your concerns and provides advice, is one of the factors that make the maneuvers effective (contextual/placebo effect).

How do I know if vestibular physiotherapy works for my type of vertigo?

There are several types of vestibular vertigo, but positional vertigo is the most common. It affects between 17% to 42% of people with vestibular vertigo.

Approximately 2.4% of the population will experience at least one episode of positional vertigo (BPPV) during their lifetime.

For example, in a town like my own (Chambéry, French Alps, 60,000 inhabitants), 1,440 people have had or will have at least one episode of positional vertigo in their lifetime.

It is important not to confuse vestibular vertigo with feelings of dizziness and vagal discomfort, often caused by orthostatic hypotension.

Healthcare professionals familiar with these different pathologies can easily determine the type of vertigo through an interview. Vertigo and discomfort caused by hypotension will not be improved through vestibular rehabilitation, although physiotherapists can also provide assistance and advice to individuals affected by hypotension.

Benign paroxysmal positional vertigo (BPPV) can occur as a result of:

• Head trauma
• Vestibular neuritis, in the weeks or months following the neuritis
• Prolonged bed rest
• An unknown cause

Physiotherapists, general practitioners, or ENT specialists perform tests to determine the type of vestibular vertigo a person is experiencing. In most cases, a few questions and one or two maneuvers are sufficient to reasonably confirm the diagnosis. There is no need for blood tests or imaging examinations (X-ray, MRI, ultrasound) to determine if vestibular rehabilitation is appropriate.

To summarize: Consult your doctor or physiotherapist. They will be able to determine if vestibular rehabilitation is suitable for your case. If you experience vertigo that gives you the sensation of spinning, lasts for a few seconds, and occurs when your head changes position (for example, when getting out of bed), there is a strong chance that your vertigo is of vestibular origin.

What does a physiotherapy session for benign paroxysmal positional vertigo involve?

A vestibular physiotherapy session for positional vertigo consists of three parts:

1. Vestibular assessment: Your physiotherapist ensures, through an interview and possibly some maneuvers, that you are indeed experiencing positional vertigo. They also determine which ear canal is affected. The maneuvers to be performed to alleviate the vertigo will vary depending on the location of the affected canal, although it is often the posterior canal that is affected.
2. The appropriate maneuvers: Your physiotherapist will then perform the appropriate maneuver(s). This typically involves the Epley maneuver, among others.
3. Post-treatment care and advice: Finally, your physiotherapist will monitor your well-being and provide you with guidance. They will give you advice on resuming your usual activities (such as driving) and how to react if vertigo episodes occur again. It is generally recommended to schedule a follow-up appointment 1 week to 1 month after the session to ensure proper progress.

Affected Canal	Diagnostic	Maneuver to Perform	Frequency
Posterior (right or left)	Dix-Hallpike test	Epley maneuver	81-89%
Horizontal/Lateral	Supine roll test	Lempert and Tiel-Wilck maneuver or Gufoni maneuver	8-17%
Anterior	Dix-Hallpike test	Nystagmus downwards and in the opposite direction of head rotation	1-3%

Maneuver for positional vertigo involving the posterior canal

Posterior canal involvement in positional vertigo is characterized by:

• Vertigo episodes lasting a few seconds to 1 or 2 minutes, especially during positional changes involving head rotation, often experienced in the morning or when getting out of bed.
• Appearance of vertigo during the Dix-Hallpike test, with or without observable nystagmus (involuntary eye movements) by the physical therapist, usually upward.

To confirm the diagnosis and determine which side of the inner ear is affected, the physical therapist performs the Dix-Hallpike test twice, once for the left side and once for the right side.

Here is the step-by-step procedure for performing the Dix-Hallpike test to assess the left side:

1. The patient is seated on an examination table, bed, or couch.
2. The practitioner turns the patient’s head 45° to the left.
3. The patient is quickly laid back on the table, while maintaining the 45° head rotation and allowing the head to extend 30° beyond the table edge.
4. The patient remains in this position for 1 minute with eyes open.
5. The practitioner observes the patient’s eyes: after a few seconds, nystagmus may appear (eyes move toward the forehead or affected ear).
6. The practitioner helps the patient sit back up.
7. To test the right side, the test is repeated with the head turned to the right. It is important to wait approximately 5 minutes before testing the other side.

Once the diagnosis is established, the Epley maneuver is performed to treat positional vertigo.

This video provides a clear demonstration of how to perform the Epley maneuver:

Here is a step-by-step description of the Epley maneuver to treat right-sided posterior canal involvement (for the left side, the same steps should be followed with the head turned to the opposite direction):

1. Seat the patient on a table or couch.
2. Turn the patient’s head 45° to the right.
3. Guide the patient to lie down on their back while maintaining the 45° head rotation and extending their head 30° beyond the table edge.
4. Wait in this position for 30 seconds.
5. Rotate the head 90° to the left, while maintaining the extension. The head will be rotated 60° to the left.
6. Wait in this position for 30 seconds.
7. Have the patient roll onto their left side. The head should rotate an additional 90°, resulting in a total head rotation of 45° to the left relative to the horizontal position.
8. Wait in this position for 30 seconds.
9. Help the person sit back up.
10. After the maneuver, the patient should remain seated for at least 5 minutes. The practitioner provides advice for the following days, such as avoiding sleeping on the affected ear, practicing balance exercises demonstrated by the therapist, being cautious in the following days as rotatory vertigo may still occur, and scheduling a follow-up appointment in 2 weeks if persistent vertigo occurs.

80% of patients treated with the Epley maneuver alone will no longer experience rotatory vertigo. If the patient is also advised to avoid sleeping on the affected side and perform balance exercises, the chances of recovery are slightly higher. However, the addition of oscillations by the practitioner during the Epley maneuver, as sometimes done, does not improve the chances of recovery.

Maneuver for positional vertigo involving the lateral canal

In case of involvement of the lateral canal (also known as the horizontal canal) of the inner ear, the symptoms are:

• Vertigo episodes that last for a few tens of seconds, or even 1 or 2 minutes, especially during positional changes involving head rotation.
• The occurrence of this type of vertigo during the Supine Roll Test, along with nystagmus (involuntary eye movements) observable by the examiner.

After the initial interview, if the physical therapist suspects involvement of the lateral canal rather than the posterior canal, they will directly perform the Supine Roll Test (also known as the Pagnini McClure test or maneuver) instead of the Dix-Hallpike test.

Often, they will still proceed with the Dix-Hallpike test, and if the results are negative, they will then perform the Supine Roll Test.

Here is a video demonstration of the Supine Roll Test:

And a step-by-step written explanation for Supine Roll Test:

1. Have the patient lie on their back and position their head at approximately 20° of flexion (e.g., by placing a cushion behind their neck or supporting their head with the therapist’s hands).
2. Rotate the patient’s head 90° to the right. If the patient is not flexible enough, place them in a right lateral decubitus position to allow for head rotation.
3. Wait for 1 minute and observe the appearance of nystagmus or vertigo.
4. Return the patient’s head to the neutral position while maintaining the flexion. Wait for 5 minutes.
5. Repeat the same procedure on the other side.

If a positive diagnosis of rotatory vertigo due to involvement of the horizontal canal is made, the physical therapist performs the Lempert and Tiel-Wilck maneuver, also known more colloquially as the “barbecue” maneuver.

Barbecue Maneuver to treat rotatory vertigo due to involvement of the lateral canal:

1. Position the patient lying on the affected side.
2. Maintain the position for 30 seconds.
3. Reposition the patient on their back.
4. Maintain the position for 30 seconds.
5. Position the patient lying on the unaffected side.
6. Maintain the position for 30 seconds.
7. While remaining on this side, the patient should flex their head as if trying to touch their chin to their sternum.
8. The patient should then roll onto their stomach in this head position, for example, by placing their forearms under their chest, and maintain this position for 30 seconds.
9. The patient returns to lying on the affected side for 30 seconds.
10. The patient sits upright for 5 minutes.

Maneuver for positional vertigo involving the anterior canal

This is the least common type of positional vertigo (less than 5% of cases).

It is diagnosed by performing the Dix-Hallpike test. Anterior canal involvement is suspected if:

• the patient experiences vertigo;
• downbeat and opposite-direction nystagmus appears in their eyes.

Unlike the other two types of canal involvement, there is no consensus on the maneuver to apply for resolving anterior canal involvement. Three maneuvers are described:

• Yacovino maneuver (also known as Deep Head-Hanging);
• Epley maneuver;
• Modified Epley maneuver.

The first two are the most commonly practiced.

How can I perform the Epley maneuver at home by myself?

In this video, an American vestibular physiotherapist explains in an educational manner how you can perform the Epley maneuver at home.

However, she also raises the same reservations regarding the relevance of applying this self-treatment method for positional vertigo.

Are the maneuvers and exercises truly effective against vertigo?

Vestibular rehabilitation (by healthcare professionals) is performed in approximately 70% of people with this type of vertigo.

• 56% of individuals are cured after a single maneuver,
• while only 21% are cured after the application of a false maneuver or without any specific treatment.
• Repeating the maneuver on the same day or during another session naturally increases its effectiveness.

30% of individuals with VPPB are not treated, either through maneuver or medication. How do these individuals progress?

In 60% of untreated people, VPPB disappears on its own within a maximum of 4 weeks. However, it persists for several months or even years in 30% of untreated patients.

What are the side effects of maneuver?

There are no serious adverse effects with long-term consequences reported in the scientific literature following vestibular rehabilitation.

The described side effects, which are not systematic, include:

• Nausea in 16 to 32% of patients.
• Dizziness in case of rapid upright positioning.
• Neck pain.

Driving after Epley maneuver: is it safe?

Having undergone a Epley or other vestibulat maneuver is not a formal contraindication to driving your car afterward. If you were already fit to drive before, there is a high likelihood that you will still be able to drive afterward.

If you had the maneuver performed by a physical therapist:

• You may need to wait a few minutes in the physical therapist’s office or in your car if you experience any dizziness.
• Normally, your physical therapist will inform you before the session if there are any risks that may prevent you from driving afterward.

Personally, the individuals I see for vestibular therapy at home are unable to drive after the session, but that is because they were already unable to drive before the session!

It often takes several days for BPPV (Benign Paroxysmal Positional Vertigo) to completely fade away.

In general, it is usually possible to drive after vestibular maneuvers like the Epley maneuver, but this can vary depending on the specific problem and the type of session performed.

Are there specialized physiotherapists for vestibular rehabilitation?

Is there a way to prevent the occurrence of further episodes of positional vertigo?

Keep in mind that just because someone experiences positional vertigo once doesn’t necessarily mean they will have it again in the following weeks, years, or even in their lifetime.

In fact, over half of the individuals who have experienced positional vertigo will never have it again.

Certain conditions are associated with a higher frequency of paroxysmal vertigo, such as diabetes, hyperlipidemia, and hypertension. By maintaining regular exercise and a balanced diet, one can increase their chances of not experiencing paroxysmal vertigo.

It has also been observed that people who frequently and extensively use computers are more prone to positional vertigo. Limiting computer usage as much as possible can help reduce the risk of BPPV (Benign Paroxysmal Positional Vertigo) or its recurrence.

Some suggest that taking vitamin D (under specific dosage conditions) may help prevent the onset of BPPV, but studies on this matter have yielded contradictory results. It does not appear that vitamin D can prevent these vertigo episodes, although individuals with vitamin D deficiency may be more susceptible to recurrent BPPV.

Clinical Case Report 1: S, female, 42 years old

S woke up one morning and couldn’t get out of bed due to sudden onset of vertigo. However, she had to get up to prepare her children for school and held onto the wall to avoid falling. She went back to bed, couldn’t go to work, and called emergency services. A doctor from the emergency medical service visited her, diagnosed her with BPPV (Benign Paroxysmal Positional Vertigo), and prescribed physiotherapy sessions.

I took care of S later that afternoon. Through the interview and vestibular tests, I diagnosed her with BPPV of the right posterior canal. I performed 2 Epley maneuvers and provided S with some instructions while reassuring her. She was concerned because she had experienced an episode of BPPV 10 years ago, but it was less intense.

We had a follow-up phone call 3 days after the maneuver. S was able to walk and drive again, but she still experienced some balance disturbances. We scheduled a new appointment for retesting and potentially performing more maneuvers, 1 week after the initial session.

The tests still showed positive results. I repeated the Epley maneuver and gave her some balance exercises.

Three days later, S was able to return to work without experiencing dizziness or balance issues.

Clinical Case Report 2: A, female, 43 years old

A was on vacation abroad when she experienced severe vertigo and vomiting. She went to the emergency department, where she was diagnosed with BPPV and prescribed medication. She returned to France earlier than planned. After 10 days, the vertigo and nausea persisted, preventing her from leaving her home. She consulted her primary care physician, who confirmed the diagnosis and prescribed physiotherapy sessions.

When I saw her 2 weeks after the onset of symptoms, the interview and tests did not definitively confirm BPPV. After discussing the benefits and risks of performing maneuvers in this context, we decided to proceed with an Epley maneuver.

We met again 7 days later. A noticed slight improvement for 2-3 days, but then her symptoms returned. I repeated the test, which was now clearly negative. We discussed the possibility that symptoms may persist despite negative test results. My goal was to reassure A and explain that after such an intense episode, it may take some time for her body to recover. Things should gradually improve in the coming days, or at worst, weeks.

We agreed to have a follow-up phone call 7 days later, and if the symptoms persisted, she would revisit her primary care physician in a week. However, she didn’t need to do so as her symptoms gradually diminished, although she was unable to work or drive for a total of approximately 1.5 months.