If you have ever been told you have BPPV — benign paroxysmal positional vertigo — you have probably also heard about the Epley manoeuvre. It is the treatment most commonly associated with the condition, and for good reason. When performed correctly on the right patient, it works. But the idea that a single Epley resolves BPPV completely and permanently is one of the most common misconceptions we encounter in practice.
Understanding what BPPV actually is, why it sometimes requires more than one session to resolve, and why it can come back after successful treatment gives you a far clearer picture of what recovery genuinely looks like.
What Is BPPV?
BPPV is the most common cause of vertigo — that brief, intense sensation of spinning that is triggered by head movements such as rolling over in bed, tilting your head back, or looking down. It occurs when calcium carbonate crystals, known as otoconia or “ear rocks,” become dislodged from their normal position in the inner ear and migrate into one of the semicircular canals.
The semicircular canals are fluid-filled structures responsible for detecting rotational movement. When otoconia enter a canal, they disrupt the normal movement of fluid, sending false signals to the brain about head position and movement. The result is a brief but often intense episode of spinning, usually lasting less than a minute, along with characteristic eye movements called nystagmus.
BPPV most commonly affects the posterior semicircular canal, but it can also occur in the horizontal or anterior canals — and the canal involved changes which manoeuvre is most appropriate.
What the Epley Manoeuvre Actually Does
The Epley manoeuvre is a canalith repositioning procedure. Through a specific sequence of head and body positions, it guides the displaced crystals out of the affected canal and back into the utricle — the part of the inner ear where they belong and where they no longer cause symptoms.
When performed correctly on a posterior canal BPPV, it is highly effective. Research consistently shows resolution rates of 70–90% with a single session. That is a strong result — but it also means that 10–30% of people do not fully resolve after one attempt.
What the research figures do not always capture is the clinical reality: that some patients need two or three sessions to achieve complete resolution, that the canal involved is not always the posterior canal, that incorrect identification of the affected side or canal leads to an ineffective manoeuvre, and that BPPV has a well-documented recurrence rate even after successful treatment.
Why One Session Is Sometimes Not Enough
There are several reasons why a single Epley may not fully resolve BPPV:
- The wrong canal or side was treated. Accurate diagnosis requires careful examination — observing the specific pattern of nystagmus produced during the Dix-Hallpike test, assessing which ear is affected, and distinguishing between canal types. Horizontal canal BPPV, for example, requires a different manoeuvre entirely (the Barbecue roll or Lempert manoeuvre). If the wrong canal or side is treated, symptoms will persist regardless of how well the manoeuvre is performed.
- Canal conversion. During a repositioning procedure, crystals can occasionally migrate into a different canal rather than exiting the system entirely. This is not a complication — it is a recognised phenomenon that can be identified and addressed — but it does mean that one session is not always sufficient.
- Partial repositioning. Not all the crystals may successfully exit the canal in a single treatment. This is more likely when there is a larger burden of debris or when patient positioning during the manoeuvre is difficult to achieve.
- Cupulolithiasis rather than canalithiasis. Most BPPV involves free-floating crystals in the canal (canalithiasis). In some cases, crystals become adhered to the cupula — the sensory structure within the canal — rather than floating freely (cupulolithiasis). This variant tends to produce more persistent symptoms and often responds less quickly to standard repositioning manoeuvres.
Recurrence: Why BPPV Comes Back
Successfully resolving BPPV does not mean it cannot return. Research places the recurrence rate at approximately 15% within a year of initial treatment, with cumulative rates rising significantly over longer follow-up periods. BPPV is particularly common in people with a history of head trauma, vestibular neuritis, migraine, or vitamin D deficiency — all of which increase the likelihood of recurrence.
This is worth knowing because patients who have been through treatment once are often alarmed when symptoms return. The recurrence does not mean the original treatment failed. It means new crystals have again become dislodged — something that can happen with age, inner ear changes, or sometimes with no clear cause at all.
What a Thorough Assessment Involves
At Aret Chiropractic, the assessment for BPPV does not begin and end with one Dix-Hallpike test and one manoeuvre. A thorough vestibular assessment involves identifying which canal is affected and on which side, distinguishing between canalithiasis and cupulolithiasis, ruling out other causes of positional vertigo that may mimic BPPV, performing the appropriate repositioning procedure for the specific presentation, and reassessing after treatment to confirm resolution or identify the need for a follow-up session.
We also discuss with patients the home exercises that can support recovery — such as the Brandt-Daroff exercises — as well as the lifestyle factors and health considerations, like vitamin D status, that may influence recurrence.
When to Seek Assessment
BPPV is a highly treatable condition. But vertigo is not always BPPV, and not all positional dizziness is benign. It is worth seeking a clinical assessment if you experience sudden, intense spinning with head movements — particularly rolling over in bed or looking up — that has not resolved within a few days, if you have had repeated episodes of similar vertigo, if dizziness is accompanied by hearing changes, tinnitus, or a feeling of fullness in the ear, or if previous treatment did not fully resolve your symptoms.
Vertigo that is constant rather than episodic, or that is accompanied by neurological symptoms such as double vision, slurred speech, or weakness, warrants urgent medical attention rather than a chiropractic assessment.
If you have been dealing with positional dizziness and want to know whether BPPV is the cause — and what treatment actually makes sense for your presentation — we are happy to assess you properly. Call us on (02) 8018 8883 to speak with Ahmad, who is one of our Chiropractors at Aret Chiropractic in North Ryde, or book online for a consultation.
References
Bhattacharyya, N., et al. (2017). Clinical practice guideline: Benign paroxysmal positional vertigo (update). Otolaryngology–Head and Neck Surgery, 156(3_suppl), S1–S47.
Epley, J. M. (1992). The canalith repositioning procedure: For treatment of benign paroxysmal positional vertigo. Otolaryngology–Head and Neck Surgery, 107(3), 399–404.
Fife, T. D., et al. (2008). Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Neurology, 70(22), 2067–2074.
Hilton, M. P., & Pinder, D. K. (2014). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews, (12).
Kim, J. S., & Zee, D. S. (2014). Benign paroxysmal positional vertigo. New England Journal of Medicine, 370(12), 1138–1147.
Parnes, L. S., Agrawal, S. K., & Atlas, J. (2003). Diagnosis and management of benign paroxysmal positional vertigo (BPPV). Canadian Medical Association Journal, 169(7), 681–693.