Health condition · Clinically reviewed
BPPV (benign vertigo), the Epley manoeuvre — and when to look for something else.
Brief position-triggered vertigo caused by displaced calcium crystals in the inner ear. The Dix-Hallpike test diagnoses it; the Epley manoeuvre treats it — often in one visit.
Why trust this guide
- 01
Clinically reviewed
Written by our editorial team and reviewed by a registered UK clinician before publication.
- 02
Sourced from guidance
Every claim is checked against NICE, ENT UK and international BPPV guidance you can see at the end.
- 03
Current for 2026
Reflects UK practice on Dix-Hallpike diagnosis and the Epley manoeuvre as first-line treatment.
Key facts
BPPV at a glance.
The essentials, in plain English — what it is, how it’s diagnosed, what actually works, and when it might be something else.
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What it is
Canalithiasis — displaced calcium crystals in the inner ear, most often in the posterior semicircular canal.
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How common
One of the most common causes of vertigo in adults, especially in later life.
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Typical episodes
Short bursts of spinning, under one minute, triggered by a change in head position.
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How it’s diagnosed
The Dix-Hallpike test — a simple bedside manoeuvre that reproduces the vertigo and nystagmus.
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How it’s treated
The Epley manoeuvre resolves symptoms in around 80% of people after a single session.
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Recurrence
Common — but very manageable. Repeat Epley, home exercises and vestibular rehab all help.
Why this guide matters
BPPV is common — and quickly treatable.
Most people leave a well-run BPPV clinic visit dramatically better than they arrived. The three points below shape everything else on this page.
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Position triggers the diagnosis
Brief spinning tied to head position is the signature — it points straight to the Dix-Hallpike test.
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The Epley manoeuvre is the fix
A minute of head positioning resolves posterior-canal BPPV in around 80% of people at the first attempt.
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Look for red flags first
Continuous vertigo, hearing loss or focal neurology are not BPPV and need a different pathway.
How the diagnosis is made
From spinning episodes to a clear plan.
The steps a UK GP or ENT clinician will normally follow, in order — so you know what to expect and why.
Phase 1 · Recognising
History, Dix-Hallpike and central screen
Phase 2 · Confirming
Imaging, ENT review and mimics
Phase 3 · Managing
Repositioning manoeuvres and rehab
- 01
Recognising
Focused history
Positional, brief spinning episodes — triggered by turning in bed, looking up or lying down.
- 02
Recognising
Dix-Hallpike test
The definitive bedside test — reproduces vertigo and typical upbeat-torsional nystagmus.
- 03
Recognising
Rule out central causes
HINTS exam (head impulse, nystagmus, test of skew) to exclude a central (brainstem/cerebellar) cause.
- 04
Confirming
MRI brain if central features
Continuous vertigo, focal neurology or atypical nystagmus prompts imaging to exclude stroke or vestibular schwannoma.
- 05
Confirming
ENT / balance clinic
Referral if symptoms are refractory, atypical, or affect a different canal (horizontal, anterior).
- 06
Confirming
Consider mimics
Ménière’s disease, vestibular migraine and vestibular neuritis all cause vertigo but behave differently.
- 07
Managing
Vestibular rehabilitation
A structured exercise programme with a specialist physiotherapist — for recurrent or residual symptoms.
Typical timeline: one to two visits from first review to a settled plan.
Symptoms
What BPPV actually looks like.
Vertigo is not the same as dizziness — here are the patterns that point to BPPV, and the ones that suggest something else.
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Positional vertigo
A spinning sensation triggered specifically by turning in bed or moving the head.
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Brief episodes
Each attack typically lasts less than a minute — even though it can feel much longer.
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Turning the head triggers it
Looking up to a shelf, reversing the car or turning quickly can set an attack off.
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Lying down triggers it
Rolling over in bed or lying flat is a classic trigger for posterior-canal BPPV.
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Nausea with vertigo
Nausea and sometimes vomiting can accompany the spinning, especially early on.
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Imbalance between attacks
A vague off-balance feeling can linger between the brief episodes.
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No hearing loss
Typical BPPV does not affect hearing — new hearing loss points elsewhere (Ménière’s, neuritis).
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When to escalate
Continuous vertigo, hearing loss, focal neurology or headache need urgent review — see the red-flags section.
Treatment
How BPPV is treated in the UK.
Repositioning manoeuvres first, rehabilitation for recurrence — what each option does, and where it belongs in the plan.
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Epley manoeuvre
The first-line treatment for posterior-canal BPPV — a sequence of head positions that moves crystals out of the affected canal.
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Semont manoeuvre
An alternative repositioning manoeuvre for posterior-canal BPPV, useful when the Epley is not tolerated.
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Barbecue roll
A rolling manoeuvre used to treat horizontal-canal BPPV, a less common variant.
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Brandt-Daroff exercises
A home exercise programme for residual or recurrent symptoms once diagnosis is confirmed.
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Vestibular rehabilitation
A physiotherapist-led programme of gaze and balance training — useful for lingering imbalance.
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Antiemetics (short-course)
A brief course only, to control nausea. They do not treat BPPV and can hinder recovery long-term.
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Investigate atypical cases
MRI, audiology or ENT review when features are unusual, or when Ménière’s or migraine is suspected.
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Balance-clinic referral
For refractory or recurrent BPPV, or when more than one canal is involved.
What this guide is based on
The sources behind every claim on this page.
UK national guidance and specialist society standards, current at the time of last review.
Key references
Guidelines and standards we relied on.
A quiet reminder
This guide is for information, not medical advice.
Your GP or ENT specialist knows your history and can tell you which parts apply to you. If in doubt, ask about the Dix-Hallpike test.
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NICE Clinical Knowledge Summary. Vertigo.
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ENT UK. Patient information on BPPV.
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American Academy of Otolaryngology - Head and Neck Surgery. Clinical practice guideline: benign paroxysmal positional vertigo (update).
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Ménière’s Society UK. Patient guidance on BPPV and related vestibular disorders.
Red flags
When vertigo points to something else.
Most BPPV is treatable at a single clinic visit. These are the situations where you should look further, or seek help today.
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Continuous vertigo
Vertigo that does not settle within a minute or two is not typical BPPV — seek review.
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Vertigo with hearing loss
New hearing loss with vertigo suggests Ménière’s, vestibular neuritis or a schwannoma — needs ENT review.
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Focal neurology
Weakness, numbness, slurred speech or double vision — call 999; consider stroke.
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Severe headache with vertigo
A new, severe headache with vertigo needs urgent assessment.
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Recent head injury
Vertigo after head injury — needs medical review, not simply Epley.
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Vertical nystagmus
Pure vertical or gaze-evoked nystagmus points to a central (brain) cause, not BPPV.
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Vertigo after a stroke
New vertigo in someone with vascular risk factors — seek same-day review.
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Vertigo in an older adult with a fall
Falls with vertigo deserve prompt assessment to prevent injury and identify cause.
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Recurrent BPPV in unusual pattern
Frequent recurrence, bilateral involvement or multiple canals — needs a balance clinic.
Living with it
A recurring problem, but a very manageable one.
Four things that make the biggest difference day to day — positions, home exercises, driving and follow-up.
A quiet reminder
A recurrence isn’t a failure.
BPPV often comes back. A quick repeat Epley, or a short course of Brandt-Daroff exercises, will usually settle it again.
- 01 Positions
Move gently after treatment
For 24-48 hours after Epley, avoid sudden head movements and sleep semi-upright if advised.
- 02 Home
Brandt-Daroff for recurrence
Simple home exercises help condition the balance system and reduce recurrence.
- 03 Driving
Wait until settled
Do not drive during an active attack — episodes are brief but disabling. Return once symptom-free.
- 04 Follow-up
Ask for repeat Epley
A single Epley works for most, but a second session or referral is entirely reasonable if it hasn’t.
Frequently asked
Everything we get asked about BPPV.
Quick answers on Dix-Hallpike, the Epley manoeuvre, recurrence and when to seek urgent help.
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What causes BPPV?
Tiny calcium carbonate crystals (otoconia) become dislodged from the utricle and settle in one of the semicircular canals — most often the posterior canal. Head movement then moves fluid inside the canal and produces brief vertigo.
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How is BPPV diagnosed?
By the Dix-Hallpike test — a bedside manoeuvre where you are laid back with your head turned and slightly extended. Typical BPPV produces vertigo and a characteristic upbeat-torsional nystagmus after a short latency.
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What is the Epley manoeuvre?
A sequence of head and body positions that moves the displaced crystals out of the affected canal and back into the utricle, where they no longer trigger vertigo. It’s quick, safe and highly effective.
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Does the Epley always work?
It resolves symptoms in around 80% of people after a single session. A repeat session, a Semont manoeuvre, or a course of Brandt-Daroff exercises can be added if needed.
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Will BPPV come back?
It often does — recurrence is common. Home exercises and, occasionally, a repeat clinic visit are usually all that’s needed.
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When should I see a doctor urgently?
If vertigo is continuous rather than brief, comes with hearing loss, headache or any focal neurology (weakness, numbness, slurred speech, double vision), or follows a head injury — seek urgent review or call 999.
Related content
Keep reading.
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Tympanometry
A quick middle-ear pressure test — often paired with hearing checks.
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Hearing test
Rules out hearing loss when vertigo has an atypical pattern.
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Brain MRI
Used when central causes of vertigo need to be excluded.
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