Written by Alex Chen
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The Epley maneuver increased the likelihood of symptom resolution in benign paroxysmal positional vertigo (BPPV) by 35% compared to control or sham maneuver (OR 4.4, 95% CI 2.6-7.4) for a NNT of 3. This is a safe and easy maneuver to perform that can improve symptoms in your patients.
Why does this matter?
BPPV is a very common cause of vertigo and is a source of a significant distress for many patients. As providers, we prescribe anti-emetics and vestibular suppressants to help patients deal with the vertigo and nausea. However, these medicines are not without side effects, especially in the older patients who may be fall risks and have other co-morbidities. The Epley maneuver (or manoeuvre in British-speak) is safe and can improve symptoms without the side effects seen in other common treatments.
Playas Gon’ Epley – 3LW
This paper looked at a Cochrane review and another recent randomized trial set in 6 EDs. For the Cochrane review, this paper specifically looks at a primary outcome of complete symptom resolution in the intervention group (Epley) compared to the sham maneuver or control group (medication only, no maneuver). Compared to the sham/control groups, Epley maneuver increased likelihood of symptom resolution (56% vs 21%, OR 4.4, ARD 35%) for a NNT of 3. There were no reported serious complications of the treatments. Nausea was the most commonly reported symptom but was not significantly different between groups.
Part of my neuro exam for “dizzy” or vertiginous patients involves a Dix-Hallpike maneuver. This works out because if it is positive, they are already in the correct position to initiate the Epley maneuver. It takes me a few minutes to complete it and if I can improve symptoms in 1 out of 3 patients without any medications, that is a win-win. Also, it seems to get patients out faster, and they tend to feel like you did something. Of course, take caution in patients with any sign of cervical spine issues, concerns for carotid/vertebral artery dissection, and atlantoaxial joint issues. Also, older patients with significant co-morbidities for stroke should still get the appropriate workup for posterior circulation issues.
Source
Epley Maneuver (canalith repositioning) for Benign Positional Vertigo. Acad Emerg Med. 2020 Apr 13. doi: 10.1111/acem.13985. [Epub ahead of print]
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Just make sure you aren’t doing the Dix-Hallpike on patients with spontaneous nystagmus. They do not have posterior canal BPPV.
Also only diagnose posterior canal BPPV with rotatory nystagmus towards their downward ear and vertical (yes, vertical!) upward nystagmus.
If horizontal nystagmus seen, it’s not posterior canal BPPV, it’s likely horizontal canal BPPV, and needs supine roll test and Gufoni maneuver.
Lastly, elderly patient with significant risk factors for stroke still get BPPV more than they get posterior circulation stroke, so if the nystagmus is diagnostic for posterior or horizontal canal BPPV, and you make them better with a particle repositioning maneuver, you don’t need to work them up for posterior circulation stroke.
Thanks for your interest in vertigo!
Love it! Your knowledge of vertigo is dizzying (yes…sadly, that was intended). Thanks again for teaching us. Yoda of vertigo, you are.
Look up Carol Foster’s maneuver. I have been doing it and teaching it for years. Works better than EPley, and patients can self administer it at home. I do it for myself at first sign of BPPV, and it immediately aborts the attack. https://www.youtube.com/watch?v=mQR6b7CAiqk
This looks very promising. Thank you so much for sharing this. The YouTube video you mentioned is incredibly helpful in demonstrating the maneuver. Here is a published report by Dr. Carol Foster. https://www.karger.com/Article/PDF/337947 .