By canal
Posterior canal
The posterior canal accounts for 80–90% of BPPV — its orientation makes it the most gravity-dependent of the three. It is also the best-studied: the Epley and Semont manoeuvres both have strong randomised evidence.
Recognising it
Posterior-canal BPPV causes brief spinning when lying down, rolling over in bed, or tipping the head back. The Dix–Hallpike test reproduces it, and the same position is where treatment begins.
The Dix–Hallpike is the gold-standard diagnostic test: a positive result shows transient torsional-upbeat nystagmus, with a short latency, lasting under a minute and fatiguing on repetition.3 The side that provokes the nystagmus is the affected side and sets the direction of the manoeuvre.
Confirm the canal and side on Dix–Hallpike before treating. Upbeat-torsional nystagmus beating toward the dependent ear localises the posterior canal; a down-beating or direction-changing pattern should redirect you to the anterior or horizontal canal, or to central causes. Post-manoeuvre postural restrictions are not required by current guidance.7
Epley manoeuvre
The canonical canalith repositioning procedure, described by Epley and now standard practice for posterior-canal BPPV. Stepwise rotation around the axis of the affected canal walks otoconia from the canal, through the common crus, back into the utricle. Resolution is 80–95% within one to three sessions.1,2
Epley manoeuvre
Patient sits upright on the table, clinician behind. The head is turned 45° toward the affected (right) ear.
Why: Aligns the posterior canal with the sagittal plane of movement.
Semont liberatory manoeuvre
An equally effective alternative that swaps Epley's slow, sequential rotation for a single rapid swing from one lateral decubitus position to the other. Its brisk angular acceleration is what frees the debris — performed slowly, it fails. It is especially useful where the Epley is contraindicated or poorly tolerated, and adapts well to self-treatment.4,5
Semont liberatory manoeuvre
Patient sits upright; the head is turned 45° to the left — away from the affected (right) ear.
Why: Orients the posterior canal so the rapid lateral movement drives debris toward the utricle.
Brandt–Daroff exercises
Not a repositioning manoeuvre but a habituation regimen the patient performs at home. Slower to work and less effective acutely, but a useful adjunct for recurrent BPPV, for residual dizziness, or when manual repositioning is impractical.6
Brandt–Daroff exercises
Patient sits on the edge of the bed, feet flat or extended forward.
Why: Baseline position to begin the habituation cycle.
Key points
- Confirm the side on Dix–Hallpike; the affected side sets the direction.
- Epley is first-line (80–95% in 1–3 sessions); Semont is an equal alternative.
- The Semont depends on a rapid swing — slow execution is a common cause of failure.
- Brandt–Daroff is for home use, recurrence and residual symptoms, not acute first-line cure.
- No routine postural restrictions are needed afterwards.