By Millie Brecheisen, physiotherapist in Basel. Updated: 1 October 2026.
You lie down, the room spins for a few seconds, then everything settles. The same dizziness returns when you roll over. This pattern suggests BPPV, although it does not establish the diagnosis on its own. Positional testing helps identify the affected canal and choose the appropriate manoeuvre.
A distinctive pattern when the presentation is typical
Benign paroxysmal positional vertigo, or BPPV, occurs when small crystals in the inner ear move into a semicircular canal. It causes brief spinning episodes when you lie down, turn in bed, look up or bend forward. Between episodes, you may feel fairly well or notice some mild unsteadiness.
Testing matters as much as the manoeuvre
Treatment should not begin with an Epley manoeuvre chosen at random. Positional tests identify the canal and side involved through the symptoms and the observed eye movements, called nystagmus. The posterior canal is most commonly affected, but horizontal and anterior canal forms also occur.
A 2023 review supports the effectiveness of the Epley manoeuvre for posterior canal BPPV [1]. Brandt–Daroff exercises sometimes have a place in treatment, but the 2024 evidence does not establish that they are better than a repositioning manoeuvre directed at the affected canal [2].
Unsteadiness can remain after successful treatment
Some people continue to feel as if they are floating after the positional vertigo has resolved. A 2024 review discusses several possible mechanisms: incomplete sensory compensation, anxiety about movement, another vestibular problem or changes in postural control [3]. Repeating the assessment is useful before performing more manoeuvres.
If brief, reproducible positional vertigo returns, persistent or recurrent BPPV should be considered. When positional tests are negative, however, the remaining symptoms may no longer be caused by displaced crystals.
When the presentation does not fit ordinary BPPV
Continuous dizziness lasting hours, weakness, double vision, a sudden inability to walk or unusual nystagmus requires a different assessment. Significant hearing changes also point towards other possible causes.
After a head injury, several canals may be involved and other disorders may coexist. Clinical reasoning remains necessary even when part of the symptom pattern looks familiar.
What happens after the manoeuvre?
Normal movements can usually be resumed. Rehabilitation may help when balance remains impaired. In Basel, the aim is to test and treat the canal actually involved, then check the result rather than apply the same sequence to everyone.
Points to remember in clinical practice
The Dix–Hallpike test assesses vertical canal presentations; the supine roll test investigates the horizontal canal. The direction, latency and duration of nystagmus help determine the canal and side. Negative positional tests combined with constant unsteadiness should prompt investigation of other mechanisms before repeating repositioning manoeuvres.
Before a manoeuvre: identify the canal and any limitations
The observed nystagmus guides the choice of manoeuvre. The Epley manoeuvre mainly addresses posterior canal BPPV. Horizontal canal forms require another strategy.
- Describe the exact position that triggers the symptoms and how long they last.
- Mention neck problems, recent surgery or any limitation that makes certain positions difficult.
- Check the result and distinguish a return of positional vertigo from residual unsteadiness.
Positions can be adapted when movement is difficult. For a first episode that has not been assessed, an online manoeuvre does not replace an examination.
An individual assessment in Basel
An assessment in Basel includes your history and suitable positional tests. If BPPV is confirmed, the manoeuvre is selected for the affected canal and side. If the spinning settles but you remain unsteady, follow-up can focus on balance and walking.
Frequently asked questions
How many sessions are needed?
Some people improve after one session; others need several, particularly when more than one canal is affected.
Can I do the Epley manoeuvre myself?
This may be appropriate for some people with a previous confirmed diagnosis. However, the manoeuvre must match the canal and side. Choosing the wrong one may be ineffective.
Why do I still feel as if I am on a boat?
Residual unsteadiness can occur. The first step is to check that the BPPV has resolved, then assess balance and other contributing systems.
Related articles
- Dizziness and vestibular rehabilitation in Basel
- Persistent dizziness after BPPV or vestibular neuritis: what next?
- Vestibular neuritis: understanding acute vertigo and recovery
- PPPD: understanding persistent dizziness and its treatment
Scientific references
[1] Effects of Epley procedure on BPPV patients: a systematic review of randomized controlled trials. 2023. Read the reference on PubMed.
[2] Effectiveness of Brandt-Daroff exercises in BPPV: systematic review of randomized controlled trials. 2024. Read the reference on PubMed.
[3] Özgirgin ON et al. Residual dizziness after BPPV management: pathophysiology and treatment beyond repositioning. Front Neurol. 2024. Read the reference on PubMed.
This information explains possible mechanisms and rehabilitation options. Diagnosis and treatment depend on an individual assessment.
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