Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

Information is supplied only upon the condition that the viewer will make their own determination as to the suitability of the information for its purposes prior to use.  There will be no responsibility for information that is misused or misinterpreted and the information should not be used as a substitute for consultation with a health care professional.  It is not possible to answer questions regarding individual cases or to enter into individual correspondence.

Benign Paroxysmal Positional Vertigo (BPPV) and Epley Manoeuvre

Benign Positional Vertigo is one of the commoner causes of dizziness and typically involves short attacks of rotational vertigo, which are brought on by rapid head movements, often involving rolling over in bed.  BPPV is a problem in the balance organ due to loose particles.  These particles are normally fixed in place but sometimes break loose and get into a particular part of the balance organ causing BPPV.  This means that whenever the head is in a certain position, the particles move and cause dizziness.  It can occur due to “debris” from otoconia, which are balance organs in the posterior semi circular canal.  When the head position changes quickly, the movement of fluid “endolymph” moves the debris which stimulates the hair cells in the affected canal and produces dizziness.  Common movements which provoke the dizziness are turning over in bed, tilting the head backwards or turning the head to one side.

Exercises have worked to “acclimatise” the brain to the difference in sensitivity of one of the canals and can include Cawthorne Cooksey or Brandt-Daroff exercises. The Epley manoeuvre is an attempt to produce a head movement to clear the debris from the affected canal; further self treatment can also improve this.

Hallpike Test

When the affected side is rotated downwards, classic nystagmus is produced which can have a fatiguability (reduced symptoms and signs of vertigo on repeated movements) and reversibility (eye movements in the opposite direction on sitting upright again).  Abnormalities in this test can indicate a central, non-peripheral, cause for the vertigo.  Other relevant tests can include audiological testing, vestibular testing and MRI scanning to assess the inner ear and the auditory and vestibular nerves where they cross the cerebello-pontine angle to enter the brain and exclude any “central” or “retrocochlear” pathology, such as an acoustic neuroma or other lesion.

Can BPPV be treated?

Many people with BPPV get better spontaneously, probably due to the loose particles dispersing on their own.  However, recent research has shown that particles can be moved to their correct place by placing the head in a series of positions.  These manoeuvres appear to be very successful in treating the condition although it does not work for everyone.  The manoeuvre is usually done once and may need to be repeated further.

Epley Manoeuvre

In this procedure the posterior canal is rotated backwards in a near vertical plane to allow the debris to move out of the posterior canal and into the larger area of the utricle where it will not cause the balance organs to be stimulated.  Vestibular sedatives can be helpful in the early stages if the BPV is severe.  Each positioning exercise is performed quickly and the end position maintained until the vertigo settles, which suggests that the endolymph flow has then stopped.

Essentially the manoeuvre involves extension of the head over the edge of the couch with the affected ear downwards followed by rotation of the head through 90 degrees towards the opposite ear and then through a further 90 degrees until the face points towards the floor, with the body rolling onto the opposite side, lying on the couch.  From this position, the subject is then sat up with the chin down.  The physiological basis is that the otolith debris in the posterior canal successively moves down the canal, away from the posterior ampulla, downwards until it reaches the crus commune (which links the anterior posterior canals).  The debris then moves along this to enter the utricle where it no longer causes vertigo.  Each head movement change occurs rapidly over one second with each of the positions maintained for at least 30 seconds.  The sequences are as follows:

  1. Sitting upright with head turned 45 degrees, towards affected side.
  2. Lie down with head dependant, towards affected side as if performing Hallpike manoeuvre.
  3. Rotate head through 90 degrees, with face upwards, maintaining head dependant position.
  4. Ask patient to roll on side while head is in this position.
  5. Rotate head further 90 degrees, so that patient faces obliquely downwards, the nose 45 degrees below horizontal.
  6. Raise patient to a sitting position whilst maintaining this head rotation.
  7. Simultaneously rotate head to central position and move 45 degrees forwards.

Spontaneous remission of untreated benign positional vertigo can take an average of ten weeks whereas Epley showed effective relief in 77% of patients after one treatment and another 20% in second trial one week later.  Try to avoid lying completely flat in bed for two days after a repositioning manoeuvre, (i.e. sleep propped up on several pillows) and also try to avoid lying on either side in bed for five days afterwards.

Self Guided Positional Exercises 

These can include six repetitions to either side and at least three sessions daily.  Whereas when an operator is performing the manoeuvre, it is useful to have the eyes open, for self guided exercises these should be closed to reduce the vertigo.  The starting position entails sitting on a bed with the head turned 45 degrees to one side and the subject then quickly lies down to the opposite side with the head still turned so that the region behind the ear touches the bed.  This should then be maintained for 30 seconds whereupon the subject should sit up again.  They then turn the head 45 degrees towards the other side and quickly lie down towards the opposite side to before.  After this, they sit up again.

Instructions following the repositioning manoeuvre

Following the manoeuvre, in order to avoid the particles going back to where they were:

  • Do not lie completely flat on your back for 2 days (sleep with several pillows)
  • Do not lie on your affected side for 5 days

After this time, try to bring on your dizziness by lying down and turning over to see if it is still there.

Will BPPV return?

Some people seem to be prone to getting BPPV and it can return on a regular basis.  This is not common and most people get it only once.  It is not possible to predict what will happen so in each case it is necessary to wait and see.

Reference Fortnightly Review: Benign Positional Vertigo: Recognition of Treatment 

Lempert, Gresty and Bronstein.  BMJ 1995; 311: 489-491