What If the Epley Doesn’t Work?
“Up to 20% of people will experience benign paroxysmal positional vertigo (BPPV) at some point in their lives.” That number always strikes me. It tells us two things: vertigo is incredibly common, and so is the frustration when the Epley manoeuvre doesn’t bring relief. I’ve seen it many times in vestibular physiotherapy practice. Sometimes the Epley works like magic. Other times it doesn’t budge the symptoms at all. And when that happens, patients often feel stuck. But here’s the good news: you’re not at a dead end. Far from it.
In this post, I’ll walk you through what I share with my own clients when the Epley isn’t enough. We’ll dig into vestibular rehabilitation, explore next steps, and show you how to move forward with clarity and confidence.
—
Why the Epley Might Not Work
When BPPV Isn’t the Only Issue
The Epley is designed for one specific problem: posterior-canal BPPV. But dizziness can stem from many sources. A thorough assessment can reveal whether you’re dealing with another canal, another condition, or a mix of factors altogether.
Sometimes the issue isn’t BPPV at all. That’s where differential diagnosis becomes essential, ensuring we’re not trying to fix the wrong problem with the right technique.
When the Crystals Aren’t Where We Think
The inner ear has more than one “loop.” If the otoconia (crystals) are sitting in the horizontal canals, the Epley simply isn’t the right treatment. It’s not that the manoeuvre failed. It’s that we didn’t target the correct structure.
When Technique Matters
Even the best clinicians need precision here. Angle, speed, head position—it all influences the accuracy of the manoeuvre. Small deviations can prevent the crystals from traveling to where we need them.
—
What to Do Next
1. Revisit the Diagnosis
Before trying anything else, confirm what you’re dealing with. A skilled vestibular physiotherapist will reassess your eye movements, symptom triggers and canal involvement. It’s a fast step that often changes the entire plan.
2. Consider the Semont Manoeuvre
If the Epley doesn’t work and your clinician confirms posterior-canal BPPV, the Semont is often the next tool we reach for. It uses momentum rather than a gradual sequence of head positions. When the canal debris is stubborn or sticky, this is the manoeuvre that sometimes cracks the case.
3. Explore Horizontal-Canal Techniques
If testing shows a horizontal-canal issue, you need a completely different approach. Techniques like the Lempert (BBQ roll) or Gufoni can be highly effective. These manoeuvres look different, feel different, and work differently because the anatomy demands it.
4. Integrate Vestibular Rehabilitation
This is where vestibular rehabilitation becomes a game-changer. It’s not just for chronic dizziness—it can stabilise lingering symptoms after successful repositioning too. I often include:
Gaze-stability training
Balance retraining
Habituation exercises
These strengthen compensation pathways in the brain and help clients feel steady and confident again.
—
When “Persistent” Doesn’t Mean “Permanent”
Don’t panic if symptoms linger
Some people feel better immediately after the first manoeuvre. Others need several attempts. And some need a blend of manoeuvres plus rehabilitation exercises over a few weeks. All of these responses are normal.
Look beyond techniques
Lifestyle factors—sleep, posture, stress, hydration, screen time—can influence symptom intensity. Small tweaks often support recovery in ways that surprise people.
—
Practical Steps You Can Take Today
Step 1: Find a vestibular specialist
Not all clinicians work with vertigo every day. A practitioner with training in vestibular physiotherapy will know exactly how to approach your case.
Step 2: Request a canal-specific reassessment
Ask for positional testing with video goggles if available. It dramatically improves accuracy.
Step 3: Keep notes
Track which movements trigger dizziness, when symptoms spike, and how long they last. This helps shape the treatment plan.
Step 4: Don’t keep repeating the Epley blindly
If it hasn’t improved anything after 2–3 correctly performed attempts, it’s time to switch strategies.
—
Final Thoughts
When the Epley doesn’t work, it’s easy to think something is seriously wrong. I see clients tense up, worried they’re out of options. But the truth is, this is just one step in a much bigger toolkit. With the right guidance, targeted manoeuvres, and vestibular rehabilitation, most people achieve long-lasting relief—even after the first attempt fails.
You’re not stuck. You’re just one tailored step away from progress. Let’s keep moving forward.
