Epley Maneuver, Step by Step — and Why the Side You Start On Matters

If the Dix-Hallpike is the question, the Epley maneuver is the answer. It is the canalith repositioning procedure for posterior canal BPPV — the treatment the AAO-HNS clinical practice guideline tells us to reach for instead of vestibular suppressants and imaging — and it may be the highest-value two minutes in all of vestibular care. It is also frequently done from the wrong side, rushed between positions, or abandoned halfway. This is the technique, step by step, and the logic behind the side you start on.

Why the side you start on matters

The Epley is not symmetrical. It is a sequence of head positions that walks displaced otoconia out of one specific posterior canal — the one your positional test just identified. Start on the wrong side and the geometry does nothing at all.

The rule is simple: you treat the side that produced the positive Dix-Hallpike. If the right Dix-Hallpike produced the upbeat-torsional burst, the right posterior canal is the culprit, and the Epley begins exactly where that test ended — supine, head hanging, turned 45° to the right. This is why we teach the test and the treatment as one continuous encounter: diagnose the canal first (the complete Dix-Hallpike guide covers how), then treat it without sitting the patient up in between.

Step by step (right posterior canal shown)

1. Start where the Dix-Hallpike ended. Supine, neck extended 20–30° past the plinth edge, head turned 45° to the right. Hold 30–60 seconds, or until any nystagmus has settled.
2. Turn the head 90° to the left — now 45° left, neck still extended. Only the head moves; the body stays supine. Hold 30–60 seconds.
3. Roll onto the left side, letting the body follow the head, until the nose points about 45° toward the floor. This is the position patients find strangest, and the one most often skipped or cut short. Hold 30–60 seconds.
4. Sit up sideways from the left side, legs over the edge, chin slightly tucked. Sit quietly for a minute.

For a left posterior canal, mirror everything.

What you may see along the way

A second burst of nystagmus in step 2 or 3 — beating in the same direction as the original — is a welcome sign: the debris is moving the way you want it to. A reversal of direction mid-sequence may suggest that the debris is falling backward, and the position was probably not held long enough. No nystagmus at all during treatment is common and not a failure.

Common faults

• Treating the wrong side — usually from testing only one side, or misreading the torsion. The recorded test lets the clinician review the torsion instead of arguing from memory.
• Rushing the holds. Each position needs its 30–60 seconds; the debris moves at its own pace.
• Losing neck extension in step 2. The head turns, but should stay dependent.
• Skipping step 3 because the patient is anxious. That position does real work — talk them through it rather than around it.
• No re-test. A follow-up positional test, same visit or at review, is the only way to know the canal is clear.

After the maneuver

The guideline is refreshingly unfussy here: post-Epley positional restrictions (sleeping upright, avoiding the affected side) have not shown convincing benefit, so we don't burden patients with them. Warn them instead that mild unsteadiness for a day or two is common, that a single repeat treatment is sometimes needed, and that symptoms which change character — new hearing loss, persistent spontaneous vertigo, neurological signs — are a reason to come back, not to repeat the maneuver at home indefinitely.

Where SmartVertigo fits

Two places. First, before the treatment: the recorded Dix-Hallpike gives the clinician a reviewable recording of the nystagmus on which to base the side decision — the single decision the whole maneuver depends on — with SmartVertigo's software-assisted classification presented as an aid to that read, never as the decision. Second, during it: the session is recorded, so the treatment that was given — side, sequence, response — is documented rather than remembered. (On-screen maneuver guidance exists in the app as an investigational feature under clinician supervision; it is not part of the FDA clearance.)

SmartVertigo™ (FDA 510(k) cleared, K260566, Class II) records, tracks, stores and displays eye movements. Its software-assisted nystagmus classification is an aid presented for the clinician's interpretation and is not part of the cleared indication; the device provides no diagnosis and no diagnostic recommendations. All findings are reviewed and interpreted by a qualified clinician. This article is education for clinicians, not medical advice. For the full framework, see the AAO-HNS Clinical Practice Guideline on BPPV.