BPPV Treatment: Are There Alternatives to the Epley Manoeuvre?
BPPV, vestibular physiotherapy and the latest repositioning manoeuvres: an evidence-informed guide
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of positional vertigo. It occurs when tiny calcium carbonate crystals, often described as crystals in the ear, become displaced into a semicircular canal of the inner ear. Specific head movements can then trigger brief episodes of spinning, dizziness or vertigo.
The good news is that BPPV often responds well to a canalith repositioning manoeuvre performed by a suitably trained healthcare professional. The Epley manoeuvre remains a well-established first-line treatment for posterior canal BPPV. However, what happens when symptoms persist despite treatment?
For patients and vestibular physio professionals alike, understanding alternative BPPV manoeuvres can help guide treatment when the initial approach is unsuccessful or difficult to perform.
Which BPPV manoeuvres are available?
The choice of manoeuvre depends on the affected semicircular canal, the likely mechanism of the crystals, the patient’s examination findings and their physical capabilities. There is no single manoeuvre that is appropriate for every type of BPPV.
The good news is that BPPV often responds well to a canalith repositioning manoeuvre performed by a suitably trained healthcare professional. The Epley manoeuvre remains a well-established first-line treatment for posterior canal BPPV. However, what happens when symptoms persist despite treatment?
For patients and vestibular physio professionals alike, understanding alternative BPPV manoeuvres can help guide treatment when the initial approach is unsuccessful or difficult to perform.
Which BPPV manoeuvres are available?
The choice of manoeuvre depends on the affected semicircular canal, the likely mechanism of the crystals, the patient’s examination findings and their physical capabilities. There is no single manoeuvre that is appropriate for every type of BPPV.
1. Epley manoeuvre
The Epley manoeuvre is a well-established treatment for posterior canal BPPV. It uses a sequence of head and body positions to guide displaced crystals towards the vestibule, where they are less likely to stimulate the semicircular canal.
Pros
Strong clinical evidence supports its effectiveness for posterior canal BPPV.
It is widely taught and used in vestibular physiotherapy.
It can often be performed in a standard treatment setting.
Cons
It requires appropriate positioning and sufficient neck and trunk movement, although adaptations may be possible.
It can provoke temporary vertigo, nausea or imbalance.
Persistent symptoms may require reassessment and further treatment rather than simply repeating the same manoeuvre indefinitely.
A Cochrane review by Hilton and Pinder (2014) found that the Epley manoeuvre was more effective than sham treatment or control for resolving posterior canal BPPV. It also found no clear difference in effectiveness between Epley and Semont in the limited direct comparisons available at that time.
The Epley manoeuvre is a well-established treatment for posterior canal BPPV. It uses a sequence of head and body positions to guide displaced crystals towards the vestibule, where they are less likely to stimulate the semicircular canal.
Pros
Strong clinical evidence supports its effectiveness for posterior canal BPPV.
It is widely taught and used in vestibular physiotherapy.
It can often be performed in a standard treatment setting.
Cons
It requires appropriate positioning and sufficient neck and trunk movement, although adaptations may be possible.
It can provoke temporary vertigo, nausea or imbalance.
Persistent symptoms may require reassessment and further treatment rather than simply repeating the same manoeuvre indefinitely.
A Cochrane review by Hilton and Pinder (2014) found that the Epley manoeuvre was more effective than sham treatment or control for resolving posterior canal BPPV. It also found no clear difference in effectiveness between Epley and Semont in the limited direct comparisons available at that time.
2. Semont manoeuvre
The Semont manoeuvre, sometimes called a liberatory manoeuvre, is another established treatment for posterior canal BPPV. It involves moving the patient rapidly between side-lying positions, with the head positioned appropriately throughout.
Pros
Supported by clinical trials and systematic reviews.
Provides an alternative when the Epley manoeuvre is unsuitable or unsuccessful.
Can be effective without using the same sequence of head movements as Epley.
Cons
Rapid transfers may be difficult for people with restricted mobility, significant frailty or poor transfer tolerance.
It can provoke marked, although usually temporary, vertigo or nausea.
Correct diagnosis and positioning remain essential.
A 2024 systematic review of 18 randomised controlled trials involving 2,237 participants concluded that the Semont manoeuvre is an effective treatment for posterior canal BPPV.
The Semont manoeuvre, sometimes called a liberatory manoeuvre, is another established treatment for posterior canal BPPV. It involves moving the patient rapidly between side-lying positions, with the head positioned appropriately throughout.
Pros
Supported by clinical trials and systematic reviews.
Provides an alternative when the Epley manoeuvre is unsuitable or unsuccessful.
Can be effective without using the same sequence of head movements as Epley.
Cons
Rapid transfers may be difficult for people with restricted mobility, significant frailty or poor transfer tolerance.
It can provoke marked, although usually temporary, vertigo or nausea.
Correct diagnosis and positioning remain essential.
A 2024 systematic review of 18 randomised controlled trials involving 2,237 participants concluded that the Semont manoeuvre is an effective treatment for posterior canal BPPV.
3. Hybrid and alternative repositioning manoeuvres
A range of other manoeuvres has been described, including the Gans manoeuvre, hybrid or universal manoeuvres, and modified techniques intended to address particular presentations of BPPV.
Examples include the Li manoeuvre, Dias or Quick Liberatory Rotation, modified Yacovino techniques, and other approaches designed for selected atypical presentations. These are not interchangeable treatments: their suitability depends on the canal involved and the suspected mechanism.
Potential advantages
They may offer options when conventional manoeuvres are difficult to perform or have not resolved objectively confirmed BPPV.
Some techniques may be adapted for patients with physical limitations.
Certain approaches are intended for specific canal variants or presentations in which standard manoeuvres may be less appropriate.
Potential disadvantages
The amount and quality of supporting evidence vary between techniques.
Some manoeuvres are supported by relatively small studies, and comparative evidence is limited.
More complex positioning does not necessarily mean better outcomes.
A systematic review and meta-analysis of the Gans repositioning manoeuvre published in 2022 reported outcomes broadly comparable with Epley in the small number of trials available. However, these findings should not be interpreted as proof that every hybrid manoeuvre is equally effective.
What does the latest evidence tell us?
A 2022 systematic review and network meta-analysis examined 41 randomised studies of treatments for posterior canal BPPV. Epley, Semont, hybrid manoeuvres and Epley combined with vestibular rehabilitation showed benefits at one week, although the results varied at longer follow-up.
A further network meta-analysis published in 2026 included 20 randomised controlled trials involving 2,089 participants. It ranked Epley highest for overall effectiveness, with Epley and Semont performing well for cure rates. However, rankings from network meta-analyses should be interpreted in the context of study quality, differences between trials and the outcomes measured.
The key message is that alternative BPPV manoeuvres can be valuable, but the evidence does not support routinely abandoning Epley in favour of a newer technique.
A range of other manoeuvres has been described, including the Gans manoeuvre, hybrid or universal manoeuvres, and modified techniques intended to address particular presentations of BPPV.
Examples include the Li manoeuvre, Dias or Quick Liberatory Rotation, modified Yacovino techniques, and other approaches designed for selected atypical presentations. These are not interchangeable treatments: their suitability depends on the canal involved and the suspected mechanism.
Potential advantages
They may offer options when conventional manoeuvres are difficult to perform or have not resolved objectively confirmed BPPV.
Some techniques may be adapted for patients with physical limitations.
Certain approaches are intended for specific canal variants or presentations in which standard manoeuvres may be less appropriate.
Potential disadvantages
The amount and quality of supporting evidence vary between techniques.
Some manoeuvres are supported by relatively small studies, and comparative evidence is limited.
More complex positioning does not necessarily mean better outcomes.
A systematic review and meta-analysis of the Gans repositioning manoeuvre published in 2022 reported outcomes broadly comparable with Epley in the small number of trials available. However, these findings should not be interpreted as proof that every hybrid manoeuvre is equally effective.
What does the latest evidence tell us?
A 2022 systematic review and network meta-analysis examined 41 randomised studies of treatments for posterior canal BPPV. Epley, Semont, hybrid manoeuvres and Epley combined with vestibular rehabilitation showed benefits at one week, although the results varied at longer follow-up.
A further network meta-analysis published in 2026 included 20 randomised controlled trials involving 2,089 participants. It ranked Epley highest for overall effectiveness, with Epley and Semont performing well for cure rates. However, rankings from network meta-analyses should be interpreted in the context of study quality, differences between trials and the outcomes measured.
The key message is that alternative BPPV manoeuvres can be valuable, but the evidence does not support routinely abandoning Epley in favour of a newer technique.
What if BPPV persists after treatment?
When a patient continues to experience vertigo after a repositioning manoeuvre, the next step should be a careful reassessment.
The 2017 American Academy of Otolaryngology–Head and Neck Surgery Foundation clinical practice guideline recommends reassessing patients within one month and evaluating persistent symptoms for unresolved BPPV or another underlying vestibular or central nervous system disorder.
A vestibular physiotherapist may need to consider:
Whether the original diagnosis was correct.
Whether the affected canal and side were identified accurately.
Whether the crystals have moved into a different canal or remain within the canal.
Whether a different BPPV variant requires a different manoeuvre.
Whether another condition is contributing to persistent dizziness or imbalance.
Repeated repositioning can be appropriate when examination findings continue to support BPPV. However, ongoing dizziness does not necessarily mean that crystals remain displaced. Residual dizziness, migraine-associated vertigo and other vestibular conditions may require a different management approach.
When a patient continues to experience vertigo after a repositioning manoeuvre, the next step should be a careful reassessment.
The 2017 American Academy of Otolaryngology–Head and Neck Surgery Foundation clinical practice guideline recommends reassessing patients within one month and evaluating persistent symptoms for unresolved BPPV or another underlying vestibular or central nervous system disorder.
A vestibular physiotherapist may need to consider:
Whether the original diagnosis was correct.
Whether the affected canal and side were identified accurately.
Whether the crystals have moved into a different canal or remain within the canal.
Whether a different BPPV variant requires a different manoeuvre.
Whether another condition is contributing to persistent dizziness or imbalance.
Repeated repositioning can be appropriate when examination findings continue to support BPPV. However, ongoing dizziness does not necessarily mean that crystals remain displaced. Residual dizziness, migraine-associated vertigo and other vestibular conditions may require a different management approach.
The role of vestibular physiotherapy
Effective BPPV treatment involves more than selecting a manoeuvre. Accurate assessment, appropriate positioning, patient education and follow-up are all important.
Vestibular physiotherapy can help confirm the likely diagnosis, guide the selection of an appropriate repositioning technique and reassess symptoms after treatment. Where indicated, vestibular rehabilitation can also address persisting balance difficulties or other vestibular impairments.
For patients, the most useful advice is to seek an assessment from a healthcare professional with appropriate expertise in BPPV and vestibular rehabilitation, particularly when symptoms persist, recur or do not follow the expected pattern.
The bottom line: Epley and Semont remain well-supported treatments for posterior canal BPPV. Alternative manoeuvres provide useful additional options in selected cases, but the best approach is guided by an accurate diagnosis and the individual patient’s presentation rather than by the novelty of the technique.
Effective BPPV treatment involves more than selecting a manoeuvre. Accurate assessment, appropriate positioning, patient education and follow-up are all important.
Vestibular physiotherapy can help confirm the likely diagnosis, guide the selection of an appropriate repositioning technique and reassess symptoms after treatment. Where indicated, vestibular rehabilitation can also address persisting balance difficulties or other vestibular impairments.
For patients, the most useful advice is to seek an assessment from a healthcare professional with appropriate expertise in BPPV and vestibular rehabilitation, particularly when symptoms persist, recur or do not follow the expected pattern.
The bottom line: Epley and Semont remain well-supported treatments for posterior canal BPPV. Alternative manoeuvres provide useful additional options in selected cases, but the best approach is guided by an accurate diagnosis and the individual patient’s presentation rather than by the novelty of the technique.
If you are experiencing positional vertigo, a vestibular physiotherapy assessment can help establish whether BPPV is the cause and identify the most appropriate treatment.
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