Practice
Safety & contraindications
Repositioning is generally safe, but the rapid and repetitive head movements it requires are not for everyone. A short screen of the cervical spine, vasculature and general fitness before you start prevents the rare but real harms.
Approach diagnostic and repositioning manoeuvres with caution in anyone with musculoskeletal or vascular vulnerability. Clear contraindications include cervical-spine instability — severe osteoarthritis, cervical spondylotic myelopathy, recent trauma or surgery — and significant vertebrobasilar insufficiency, where aggressive neck movement risks transient ischaemia.1 In these patients, supine-based manoeuvres such as the Gufoni or Yacovino place less stress on the cervical spine and are generally safer.
Can I treat this patient?
Select any risk factors present — the screener flags what to prefer, approach with caution, or avoid.
No specific contraindication flagged
Still screen the cervical spine, vasculature and cardiovascular status, and exclude central mimics, before any head-hanging or rapid manoeuvre.
- PreferEpley
- PreferSemont
- PreferBrandt–Daroff
- PreferLempert roll
- PreferGufoni (geotropic)
- PreferGufoni (apogeotropic)
- PreferForced prolonged positioning
- PreferCasani / Zuma
- PreferYacovino
- PreferDeep head-hanging
- PreferReverse Epley
A teaching aid, not a substitute for clinical judgement — confirm contraindications and the affected canal before treating.
The full picture
The screener distils the tables below — keep them as the reference for the conditions to look for and the actions they imply.
| Condition | Implication / recommended action |
|---|---|
| Unstable cervical spine (RA, cervical myelopathy, fracture) | Avoid head-hanging / neck rotation; use modified supine-based manoeuvres (Gufoni, Yacovino). |
| Severe vertebrobasilar insufficiency | Risk of ischaemia on neck movement; perform only under supervision or avoid. |
| Recent head/neck trauma or surgery | Defer positional manoeuvres until cleared by the relevant specialist. |
| Acute severe cardiopulmonary compromise | Delay until stable; induced vertigo and positioning add load. |
| Condition | Implication / recommended action |
|---|---|
| Moderate cervical spondylosis | Proceed with caution; use gentler or supine-based manoeuvres. |
| Advanced age or frailty | Supportive assistance; avoid sudden positional shifts; prefer Gufoni. |
| Visual impairment or balance instability | Supervise; fall-prevention measures. |
| Anxiety or vestibular migraine | Pre-explain; consider anxiolytic or migraine prophylaxis. |
| Condition | Implication / recommended action |
|---|---|
| Poor neck mobility | Use smaller angular movements; avoid forced positions. |
| Vertigo-induced nausea / vomiting | Pre-treat with vestibular suppressant; have an emesis basin ready. |
| Risk of fall post-manoeuvre | Observe 10–15 min; ensure supervised ambulation. |
| Transient residual dizziness | Reassure — may persist hours to days; distinguish from true recurrence. |
| High recurrence (~30%/year) | Teach self-CRP; schedule periodic follow-up. |
Optimising technique and tolerance
Screen cardiovascular status, neck range of motion and vascular integrity before starting, and support frail or elderly patients throughout. Move the head briskly and precisely into provocative positions — hesitant movement causes false-negative tests — while monitoring eye movements with Frenzel goggles or video-oculography where available. Counsel patients that mild residual dizziness for a few days after successful repositioning is expected and self-limiting, and is not the same as recurrence; recurrence itself affects about 30% within the first year, so teach self-administered repositioning where appropriate.2
Key points
- Screen the cervical spine and vasculature before any head-hanging or rapid manoeuvre.
- Unstable cervical spine or severe vertebrobasilar insufficiency: use supine-based manoeuvres or avoid.
- Support frail, elderly and visually-impaired patients; observe for falls afterwards.
- Residual dizziness for days is normal; recurrence (~30%/year) is common — teach self-CRP.