Vertigo? Why the Epley may not work

Vertigo can be a disorienting and distressing condition that affects balance and spatial awareness. Many people look to treatments like the Epley Maneuver to relieve symptoms caused by benign paroxysmal positional vertigo (BPPV). However, the Epley Maneuver may not be effective for everyone. So let's explore the reasons why the Epley Maneuver might not be working for you and the importance of individualized treatment plans.

Understanding Vertigo

Vertigo describes a sensation of spinning of yourself (internal vertigo) or your environment (external vertigo). Various conditions can trigger this sensation, with BPPV (Benign Paroxysmal Positional Vertigo) being the most common culprit. However, people can experience vertigo due to Vestibular Neuritis, Vestibular Migraine, Meniere's Disease, or even certain types of strokes. Therefore...

Vertigo is not a diagnosis. It is a symptom.

Other Causes of Vertigo

Because vertigo can stem from different pathologies in your inner ear or your brain, the Epley maneuver may not be the appropriate treatment for your specific source of vertigo. If fact, performing the Epley when you have one of these conditions can sometimes make your symptoms even worse! Recognizing these causes is essential for correctly diagnosing vertigo and ensuring appropriate treatment.

1. Vestibular Neuritis: This condition occurs when the vestibular nerve becomes inflamed, often following a viral infection. Symptoms can include intense vertigo that lasts several hours to days that gradually improves.

   
   

2. Vestibular Migraine: This it the most common cause of neurological dizziness and depending on what study you read, possibly more common than BPPV. Vestibular Migraine is characterized by episodes of vertigo lasting hours or days, with additional symptoms such as light or sound sensitivity, visual aura, or an actual migraine (but not always).

   
   

3. Meniere's Disease: Characterized by episodes of vertigo, hearing loss, tinnitus, and a feeling of fullness in the ear, is thought to be caused by a build-up of fluid in the inner ear.

   
   

4. Anterior Inferior Cerebellar Artery Stroke: A stroke in this particular region of the brain can produce sensations of vertigo, along with hearing loss and incoordination. This is a source of vertigo that should be treated immediately.

   
   
   
   

So when does the Epley Maneuver work?

The Epley Maneuver is effective for certain types of BPPV. I know...first here are many sources of vertigo, and now there are many types of BPPV? Bear with me. BPPV occurs when tiny debris of calcium carbonate known as otoconia (commonly referred to as "crystals") in the inner ear get dislodged. These otoconia normally reside in the otolith organs, a specific part of your vestibular system (see image below). Sometimes they get dislodged from the otoliths and fall into one of the three semicircular canals (anterior, posterior, or horizontal). This can happen spontaneously, mechanically (in the case of head trauma or a concussion), and due to age as we lose calcium in our bones (osteoporosis).

The Epley Maneuver is effective for treating BPPV in the Posterior Semicircular canal only.

While the posterior canal is the most common place the displaced otoconia settle, they can also migrate to the horizontal canal, and very infrequently to the anterior canal. To make matters more complicated, they can settle in different parts of each of these canals. So even if the otoconia are displaced in the posterior canal, they may not be in the specific part of the canal for which the Epley is the effective treatment!

So how do vestibular therapists know what canal the otoconia are in? Your eyes are intricately linked to the vestibular system via the vestibular ocular reflex. When we position your head in specific directions, we can observe your eye movement using infrared video goggles. If you have BPPV, your eyes will produce a jerking motion called nystagmus. Some patients say they can feel this. The direction and duration of the nystagmus tells us which canal and where in that canal the otoconia are!

When to Seek Professional Help

1. If you are experiencing vertigo, it is vital to consult a healthcare professional. If that healthcare professional tells you to perform the Epley Maneuver, aske them 1) if they are certain your vertigo is caused by BPPV, and 2) to show you how to correctly and safely perform the maneuver.

   
   

2. The Epley is 91% effective after 1-2 treatments (1). So, if you have an accurate diagnosis of BPPV but your symptoms are not resolving or are getting worse with the Epley, seek out a specialized vestibular physical therapist. A directory of specialists across the United States is provided below.

   
   

   Academy of Neurologic Physical Therapy Map of Vestibular Providers

   
   

   Vestibular Disorders Association Healthcare Directory

   
   

3. If your vertigo is caused by something other than BPPV, consult a healthcare professional. You may benefit from vestibular rehabilitation, or need to consult an ENT or neurologist for further examination.

   
   

In Conclusion

While the Epley Maneuver is a reliable treatment for posterior canal BPPV, it is not a one-size-fits-all solution. The diverse nature of vertigo, coupled with its many underlying causes, underscores the importance of personalized treatment plans tailored to each patient's specific needs.

If you are experiencing vertigo, consult a healthcare professional without delay. Accurate diagnosis and suitable treatment are crucial for your recovery and restoring balance in your life. Keep in mind that while the Epley Maneuver may play a role in your management, it is only one of many tools available to address vertigo effectively.

References

1. Nunez RA, Cass SP, Furman JM. Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2000 May;122(5):647-52