Treatment · Introduction
Therapeutic manoeuvres
Most positional vertigo can be cured at the bedside, in minutes, with the right repositioning manoeuvre for the right canal. This chapter is organised the way you treat — by canal — with a step-by-step animation for every manoeuvre.
Why repositioning works
Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Tiny crystals — otoconia — that normally sit in the utricle come loose and fall into one of the balance canals of the inner ear. There they make the canal sensitive to gravity, so every time the head moves the room seems to spin for a few seconds.
A repositioning manoeuvre is a careful sequence of head and body positions that uses gravity to roll those crystals back out of the canal to where they belong. Done correctly, it often stops the vertigo straight away.
BPPV affects 2–3% of people in their lifetime, more often women, with a peak between 50 and 70 years.1 Dislodged otoconia enter a semicircular canal and render it gravity-sensitive — the mechanism of canalithiasis (free-floating debris) or cupulolithiasis (debris adherent to the cupula).
The canalith repositioning procedure (CRP) leverages gravity and canal orientation to relocate that debris through the common crus back into the utricle. The posterior canal is involved in 80–90% of cases, the horizontal canal in 10–15%, and the anterior canal in a rare 3–12% — and each demands a different manoeuvre.
Treatment is canal-specific, and getting the canal and side right is the whole game. Posterior-canal BPPV is treated first-line with the Epley, supported by RCTs and a Cochrane review.3,4 The 2017 AAO-HNS guideline endorses repositioning and, notably, finds routine post-manoeuvre postural restrictions unnecessary.2
Before any manoeuvre, confirm the diagnosis and exclude central mimics: in acute vestibular syndrome a central HINTS pattern is more sensitive than early MRI for posterior-circulation stroke.5 Direction-changing or vertical nystagmus, and symptoms that persist despite correct repositioning, are red flags for imaging.
BPPV by the numbers
BPPV is common, skews female, peaks in later middle age, and recurs in roughly a third of patients within a year — yet the great majority resolve with the right manoeuvre.1,2 The posterior canal dominates, which is why its manoeuvres are the ones you reach for most.
Which canal?
share of BPPV cases- Posterior canal — 80–90%
- Horizontal canal — 10–15%
- Anterior canal — 3–12%
How this chapter is organised
Work the way you treat. Localise the canal and side at the bedside, then turn to that canal's page for the manoeuvre — each one carries an animated, step-by-step figure you can scrub through or play.
- Posterior canal — Epley, Semont, Brandt–Daroff. The common variant and the best evidence.
- Horizontal canal — Lempert (barbecue), Gufoni, forced prolonged positioning, Casani/Zuma. Geotropic vs apogeotropic forms.
- Anterior canal — Yacovino, deep head-hanging, reverse Epley. The rare, non-lateralising variant.
Then step back to the principles: the mechanisms and biomechanics that make manoeuvres work, the comparative evidence, a full diagnostic-to-treatment algorithm, and the safety and contraindications that govern who you can treat and how.
Key points
- BPPV is common, peripheral and usually curable at the bedside with repositioning.
- Treatment is canal-specific — localise the canal and side before you treat.
- Posterior canal: Epley first-line; Semont an equal alternative; Brandt–Daroff for home/recurrence.
- Horizontal canal: Gufoni or Lempert for geotropic; convert apogeotropic first.
- Anterior canal: Yacovino first-line because it needs no side determination.
- Screen for cervical and vascular contraindications, and exclude central mimics before treating.