Otoconia
Microscopic calcium-carbonate crystals that normally sit in the utricle. Patients often hear them called crystals, particles, rocks, or canaliths.
DizzyDoctor clinical guide
Epley & canalith repositioning maneuvers
BPPV treatment is not one maneuver for every patient. We identify the involved ear, semicircular canal, and particle behavior, then use the eye-movement pattern to select and verify the appropriate repositioning maneuver.
Confirm the pattern before treating it
These videos are educational and are not a substitute for an examination. The wrong side or maneuver can fail, convert BPPV into another canal, or delay evaluation of a condition that is not BPPV. Do not attempt a home maneuver unless a qualified clinician has identified your pattern and confirmed that the movement is safe for your neck, back, circulation, and mobility.
Our clinical sequence
Diagnosis directs the maneuver
BPPV is a mechanical inner-ear disorder, but the treatment plan is built from the history, positional testing, and nystagmus rather than symptoms alone.
- 01
Recognize the timing
Typical BPPV causes brief attacks of spinning or motion triggered by rolling in bed, lying back, looking up, bending, or rising.
- 02
Provoke the pattern
Dix-Hallpike, side-lying, straight head-hanging, and supine roll tests are selected according to the suspected canal and the patient’s mobility.
- 03
Record the eyes
Latency, direction, torsion, duration, fatigability, and reversal of nystagmus help localize the ear, canal, and mechanism.
- 04
Reposition and retest
The chosen maneuver is followed by repeat positional testing when appropriate. Persistent or changed nystagmus may require another maneuver or a revised diagnosis.
Clinic terminology
The words describe where the particles are and how they move
Canalithiasis
Free-floating otoconia within a semicircular canal. Movement creates a transient fluid deflection, so the positional nystagmus typically has latency and fades.
Cupulolithiasis
Particles attached to or affecting the cupula. The nystagmus may begin quickly and persist while the provoking position is maintained.
Canal conversion
Particles move from one canal into another during testing or treatment. A new nystagmus pattern calls for repeat localization, not automatic repetition of the first maneuver.
Pattern recognition
Canal, side, and mechanism must agree
This is the language used to organize a positional examination. Nystagmus must be interpreted in the full clinical context, especially when it is persistent, purely vertical, atypical, or does not respond as expected.
| Suspected location | Typical provoking test | Typical observed pattern | Common treatment direction |
|---|---|---|---|
| Posterior canal | Dix-Hallpike or modified side-lying | Upbeating and torsional; the upper poles beat toward the involved ear in classic canalithiasis | Side-specific Epley/canalith repositioning; Semont-type liberatory maneuver in selected cases |
| Horizontal/lateral canal | Supine roll test | Direction-changing horizontal nystagmus: geotropic or apogeotropic. Relative intensity and secondary signs help determine the involved side. | Lempert/barbecue roll, Gufoni, Appiani, or another variant matched to the mechanism and side |
| Anterior/superior canal | Straight head-hanging and/or Dix-Hallpike | Downbeating with a torsional component may occur. Central and atypical posterior-canal patterns must also be considered. | Deep head-hanging/Yacovino or a side-specific reverse maneuver after careful localization |
Important: Geotropic does not simply mean “the side that feels worse,” and apogeotropic lateral-canal BPPV may represent more than one particle location. That is why the eye recording and response to each position matter.
Treatment selection
“Epley maneuver” is only one part of canalith repositioning
The aim is to guide displaced otoconia through the involved canal and back toward the utricle. The sequence changes with anatomy and particle behavior.
Posterior-canal canalithiasis
The side-specific Epley maneuver is a standard first-line treatment. A Semont or modified maneuver may be selected for anatomy, mobility, cupular involvement, or treatment response.
Horizontal-canal BPPV
Geotropic and apogeotropic variants are not treated identically. The clinic may use a Lempert roll, Gufoni, Appiani, Zuma, forced prolonged positioning, or a staged conversion strategy.
Anterior-canal BPPV
A deep head-hanging or Yacovino-type maneuver can be used when the findings support anterior-canal involvement. Downbeat positional nystagmus warrants careful neurologic interpretation.
Multi-canal, bilateral, or recurrent BPPV
Treatment is prioritized by the clearest or most symptomatic pattern, then repeated testing determines whether another canal or ear also requires treatment.
Clinic video library
Side-specific treatment demonstrations
Use the sequence assigned by your clinician. Pause if you develop neck or back pain, fainting, new weakness or numbness, a severe headache, vision or speech change, or symptoms unlike your familiar positional vertigo.
Right posterior-canal canalithiasis
A right-sided canalith repositioning sequence for a confirmed right posterior-canal pattern.
Left posterior-canal canalithiasis
A left-sided canalith repositioning sequence for a confirmed left posterior-canal pattern.
Right lateral-canal BPPV
A right-sided lateral-canal repositioning sequence selected after supine roll testing.
Left lateral-canal BPPV
A left-sided lateral-canal repositioning sequence selected after supine roll testing.
Complex positional vertigo
When bedside maneuvers are not enough
Severe symptoms, restricted mobility, multi-canal disease, difficult localization, repeated treatment failure, or canal conversion may call for computer-assisted testing and treatment. The Epley Omniax and TRV chairs allow controlled multi-axis positioning while nystagmus is observed or recorded.
After the maneuver
Recovery, retesting, and recurrence
What can be normal
- Brief nausea, disequilibrium, or motion sensitivity after treatment.
- Mild residual “off” or floating sensations even after the spinning and positional nystagmus resolve.
- More than one treatment session when particles persist, convert, or involve multiple canals.
What we recommend
- Move carefully until you know how steady you are, and use fall precautions when needed.
- Return to ordinary activity as tolerated unless your clinician gives you a specific restriction for another medical reason.
- Follow the clinic’s retesting plan. Persistent symptoms should be reassessed rather than repeatedly self-treated.
What is not routine
- Sleeping upright, wearing a cervical collar, or avoiding the treated side after a standard posterior-canal maneuver is not routinely required.
- Vestibular-suppressant medication is not the routine treatment for BPPV because it does not reposition particles.
- Imaging is not routinely needed when the history and examination meet typical BPPV criteria and no additional concerning signs are present.
Not typical BPPV
Seek urgent evaluation for new neurologic or hearing symptoms
- New weakness, numbness, facial droop, double vision, confusion, or difficulty speaking
- New inability to stand or walk, fainting, severe unremitting headache, or chest pain
- Sudden hearing loss, new one-sided hearing change, or continuous severe vertigo unlike prior brief positional attacks
- Persistent downbeat, purely vertical, direction-fixed, or otherwise atypical nystagmus requiring neurologic assessment
Common questions
BPPV treatment FAQ
How do I know whether the right or left ear is involved?
The provoking side alone is not enough. The diagnosis comes from the direction and intensity of nystagmus during canal-specific positional tests. Lateral-canal patterns are particularly easy to misidentify without observing both sides.
Why did the maneuver make the pattern feel different?
Particles may have moved without fully exiting, entered another canal, or revealed a second involved canal. The next step is repeat positional testing so the new pattern can direct treatment.
Can BPPV come back?
Yes. Recurrence does not necessarily mean the first treatment failed. A new episode may involve the same ear and canal or a different pattern, so relocalization is important before repeating a maneuver.
What if spinning stops but imbalance remains?
Residual dizziness can persist after successful repositioning. The clinician may recheck for remaining BPPV and consider vestibular rehabilitation, migraine, neuropathy, medication, cardiovascular, or neurologic contributors when symptoms continue.
Should everyone do the Epley maneuver at home?
No. Home treatment is most useful after the diagnosis, side, sequence, and safety considerations are established. A history of significant neck or back disease, vascular concerns, retinal problems, recent surgery, severe mobility limitation, or an atypical examination deserves clinician guidance.
Clinical references
Evidence and further reading
AAO-HNSF Clinical Practice Guideline: BPPV (Update)AAO-HNSF BPPV guideline resourcesHorizontal-canal BPPV treatment reviewDizzyDoctor nystagmus resource
Educational content only. Diagnosis and treatment must be individualized by a qualified clinician.
San Diego otoneurology
Call (858) 223-2172Still spinning when you roll, lie back, or look up?
We evaluate the eye-movement pattern, localize the involved canal, and build a treatment plan for straightforward, recurrent, and complex positional vertigo.