You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous.

Is your first-line treatment meclizine or benzodiazepines?

Trick of the Trade

Epley maneuver (Canalith Repositioning Procedure) 1

Although the 2004 Cochrane review states that the Epley maneuver is of questionable benefit, a 2010 systematic review demonstrated that there is a significant benefit from Epley maneuver. The trick is remembering all of the steps correctly.

  • The first position is really the Dix-Hallpike maneuver in the direction (right vs left) which causes more vertigo or nystagmus.
  • Wait 30-60 seconds.
  • While remaining supine with the head extended 25-30 degrees, rotate the head 90 degrees until it is facing the other shoulder.
  • Wait 30-60 seconds.
  • Have the patient cross his/her knees and arms.
  • Have the patient roll onto his/her side (same side as looking towards) while keeping the head facing the shoulder. This positions the face so that it is almost now facing the floor. If done correctly, this should exacerbate the vertigo because the canaliths are repositioning themselves.
  • Wait 30-60 seconds.
  • Assist the patient in sittting up by swinging their legs off the edge of the table and sitting up “like a windshield wiper”.
  • Lastly, have the patient look downward around 30 degrees.

You can recommend that your patient look at YouTube videos at home to help remind them of the steps that they can do at home every night.

Helminski J, Zee D, Janssen I, Hain T. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010;90(5):663-678. [PubMed]
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at https://t.co/50EapJORCa Bio: https://t.co/7v7cgJqNEn
Michelle Lin, MD