The answer to the question about treating both sides is a bit more complicated. If you have BPPV on both sides or are not sure which side you have BPPV then you can indeed treat both sides. People often ask if you can “undo” the Epley maneuver by treating the left side immediately after treating the right side. No you can’t. However, you can cause yourself to be more nauseous and may even throw up. Even worse you run the risk of converting posterior BPPV to horizontal BPPV. What is that you ask,… Well usually people have Posterior canal BPPV meaning the crystals are in the back most balance canal. When you do the treatment maneuver the crystals come out of this canal and float back into the vestibule of the vestibular apparatus (the balance organ). If you get a lot of these crystals floating around in there and then start rolling around again they can float into another balance canal – the horizontal canal. This is actually a much worse feeling BPPV. Luckily it is easily treating by a log roll (something you might accidentally do in bed) so it usually doesn’t last very long.

So in summary we suggest getting a proper diagnosis for BPPV – and treating the appropriate side. If you are unsure on which side you have BPPV or have it on both sides we suggest treating one side for one week then treating the other side for the next week. This avoids confusion as to the diagnosis and also avoids nausea and conversion to Horizontal BPPV.

Like many things the answer isn’t perfectly clear. However, many studies have been done on each one and results have been reported with each maneuver. I’ll address each one below.

1) Brandt-Daroff maneuver (this example is for the Right side):
This maneuver consists of sitting upright with your feet over the side of your bed, lying on your right side with your right ear against the bed, or with your head turned to the left. This first step brings the BPPV particles in your semicircular canals about 1/2 way around the bend of the canal (causing vertigo). Then sitting up. This allows the particles which have moved 1/2 way around to begin to fall back down the same way they came from. Then lying down on your left side with your left ear against the bed or turned a little to the right. This doesn’t really affect right sided particles as it puts the canal in a horizontal position but may stimulate symptoms in left sided BPPV if you have it in both ears.

What this maneuver does is create and stimulate the worst of vertigo in patients with BPPV but doesn’t actually treat the underlying cause. As such it is useful to habituate yourself to your vertigo. However, in light of the following two maneuvers I see no need to ever conduct this maneuver.

2) Semont maneuver.
There are two important differences between Semont and Brand-Daroff maneuvers. 1) Speed and 2) keeping your head pointing toward your left shoulder. Lets go over the example again for the right ear.

Start sitting then lie down on your right side. It is important to turn your head to the left and look up at the ceiling. This will stimulate BPPV. Stay there until the vertigo passes. Now QUICKLY sit up and lie on your left side but KEEP your head pointing over your left shoulder during the entire time. You should now be facing down to the ground. Do not turn your head. Wait there until any vertigo passes. Then sit up.

What has happened here is that the particles move into the bend of the semi-circular canals during the first positions, then when you quickly sit up they don’t have a chance to fall back. Finally, by looking towards the ground on the other side they fall out of the semi-circular canals all together.

Since this maneuver requires speed it can be difficult for the elderly. However, it requires less neck flexibility.

3) Epley maneuver.
This maneuver and the Semont maneuver share the beginning and ending head positions relative to gravity which is why they both work. (start on back with head facing ceiling, end on other side facing the floor). The Epley maneuver is not speed dependant as it doesn’t rely on momentum to carry the particles over the hump of the canal and down the other side.

The maneuver begins on the back with the head turned to the right. In the second step the person rolls their head to the left, then up onto the left shoulder and looks to the ground, then sits up.

Summary

There are a number of devices to help perform the Epley maneuver and most publications now recommend the Epley as the first choice of maneuvers unless there is some contraindication. To my mind there is no role for the Brandt-Daroff exercises unless both the Epley and the Semont maneuvers have failed.

To be honest, as someone who has had BPPV myself, it was really scary for the first few minutes. The irony that I had BPPV was not lost on me. However, until I confirmed for myself that I did have BPPV I was a little worried that maybe I was having a stroke or an aneurysm or something of the like.

Right after I woke up I rolled to the left to get out of bed and it literally felt like the bed got up and smacked me in the side of the held. What had actually happened, of course, was that I had fallen back down onto the bed, but it sure didn’t’ feel like that. Following the initial shock I just held onto the sheets, hoping it would end. I am not sure what I said but I had called my wife in to take a look at me. From her standpoint all she could see was a man half out of bed holding on to the comforter for dear life. After what seemed like ages, but was perhaps 30 seconds, things slowed down, the ride ended and I could see straight again.

Afterwards I felt quite nauseous but didn’t need to throw up. I was, however, a bit afraid to move. Nevertheless, my curiosity got the better of me and lied back down on the bed and I rolled to the left again. Not surprisingly the ride started all over again. This time my wife was ready to look in my eyes and sure enough I had nystagmus, which confirmed the diagnosis of BPPV. In hind sight, perhaps I should have waited longer to conduct my experiment as following the second episode I spent the rest of the morning near the toilet bowl.

Once I had fully recovered and was brave enough to perform my own Epley maneuver I got ahold of the treatment device, put it on, and went through the maneuvers. Of course you do get dizzy during the treatment maneuver but ideally it will be the last time you will spinning. The maneuver went by with tolerable vertigo but towards the end I felt something odd. From a medical standpoint there is a second phase of nystagmus, when you roll up onto your opposite shoulder, just as the particles drop out of the posterior semi-circular canal and back into the utricle of the vestibular apparatus. Perhaps I imagined it, but I am sure I could feel a drop, or a change, or something that was different all of a sudden. I was relieved but not really back to normal. I tried to make myself dizzy again but couldn’t – success – sort of. I was left feeling off balance, wondering if it had really worked or if something else was going on. This feeling lasted a good two weeks. I was never spinning again since that first day (as I treated myself immediately) but I was surprised how long it took to get back to normal and for the off balance feeling to go away. That was about 6 months ago – no more episodes – yet.

Everyone describes their own symptoms differently – feel free to comment on yours below.

The answer depends on what you mean exactly. Many medications can cause dizziness. This can be the light headedness associated with blood pressure medications to the woozy feeling from narcotics to the sleepy feeling of sedatives. However, vertigo (spinning dizziness) is not often caused by medication unless damage is being done to the organ of balance in the inner ear.

In some cases damage can be temporary or it can be permanent. Some medications selectively target the balance portion of the inner ear and some target the hearing portion. The effects can either be permanent or may go away when the drug is stopped.

So yes – some medications can cause vertigo.

Of all drugs aminoglycoside antibiotics are the most vestibulotoxic (ex gentamicin) and are irreversible. Gentamicin in particular effects only the balance portion of the inner ear and causes vertigo.

Loop diuretics such as furosemide (Lasix) cause reversible ototoxicity, but often affect hearing.

Antineoplastic drugs such as cisplatin cause irreversible ototoxicity (typically they affect hearing only)

Salicylates such as asprin can cause reversible ototoxicity.

Quinine, which was historically used to treat malaria, can cause both vertigo and hearing loss.

Of course these comments are to be taken in a general context and any drug related concerns should be discussed with your own doctor.

However, usually in active BPPV you get dizzy during the maneuver. Many people find this repeated vertigo too much to do again and again. Usually BPPV causes nausea but not vomiting, unless of course you induce the vertigo over and over by repeating the maneuver.

This is the reason I suggest you only do it once or twice a day.

Further, it is not know if multiple maneuvers within a single day is actually more effective than a single maneuver as there is something called fatigue. Fatigue is when, despite the BPPV still being there, you are no longer able to make yourself more dizzy. Perhaps this is something like riding a roller coaster again and again. Eventually it won’t make you sick anymore in the same day. The Nystagmus (eye motion seen by your doctor when you are dizzy) also fatigues so it is difficult to tell much when you have repeated the maneuvers several times. As such some doctors will perform the maneuver up to 3 times in hopes of it being more effective, but there is no evidence for the same day, others will do it only once in a day. There is evidence that a second maneuver ( at a later date) will increase the success rate of the treatment from about 80% to 90%. This is one of the reasons using a self treatment device is useful. You can repeat the maneuver at home and increase your success.

We usually recommend 1-2 times per day for 1 week (or less if there is no more vertigo during the maneuver). If there is still vertigo after 1 week then do the other side. If there is still vertigo after appropriately treating both sides then consult with your physician again about the cause of the dizziness.

There are, however, factors which make dizziness worse. Age, head trauma and inner ear infections are risk factors for BPPV. Stress, depression, caffeine and alcohol make the experience of dizziness worse also. Any inner ear condition like Menieres disease has also been associated with an increased risk of BPPV.

So, what can be done? Reduce stress where possible and avoid medications or drugs to reduce possible side effects. Prophylactic maneuvers have thus far not demonstrated efficacy but they don’t hurt either. I’d be interested to hear if anyone is having any luck at prevention themselves.

As usual – discuss all medical issues with your own physician.

This is a common question and has an interesting, if theoretical, answer. It seems that some people can tell when they have BPPV just by the way they feel, even if they don’t experience vertigo at that moment. They just feel off, like something isn’t right. It is almost as if they can feel the particles sitting in the posterior semi-circular canal. This feeling goes away after they get used to the particles being in the canal. These people still experience spinning vertigo when they lay down or move in such a way as to stimulate BPPV. Interestingly, when they undergo treatment for BPPV with the maneuver and the particles are suddenly gone they again feel odd. Some describe a sense of being off balance, or even lightheadedness. It seems as if they miss the particles after having become used to them. Again this feeling goes away after about 1-2 weeks and you return to normal. There is no need to continue repeating the treatment maneuver at this point unless you are still experiencing spinning vertigo.

This whole sequence of events can be prevented by rapidly undergoing treatment before your brain has had a chance to become accustomed to the presence of the particles in the ear canals.

As always it is important to consult your own physician about your specific symptoms, especially if they change or do not fit with your usual experience or expectations.

The quick answer is no the Epley maneuver does not work for horizontal or superior canal BPPV but only for the more common posterior canal form of BPPV. The good news about that, however, is that those other two types are easier to treat.

First – superior canal BPPV is theoretical and may not actually exist in any significant clinical form. This is because BPPV is caused by the settling of lose “otoconia” in the inner ear. This can only happen in the lowest areas of the inner ear. For example – dust does not settle on the ceiling, rather it settles on the floor. The same is true of the inner ear. The particles settle, typically in the posterior canal because it is the lowest area and it is not tipped upside down by regular activity. By contrast – the superior canal is emptied every time you lie down and stand up. So, while it is possible to have crystals in that canal, it is not possible to have then “get stuck” there and cause BPPV.

The same is true, to some degree, with the horizontal canal. Whenever you roll over (like a log roll) the canal is emptied. So many times simply sleeping at night (when you may roll over) is curative for that condition. It is, however, more intense vertigo than posterior BPPV. It is worth noting that horizontal BPPV can sometimes be induced by the treatment maneuvers for posterior BPPV as the crystals may fall out of the posterior canal and temporarily fall into the horizontal canal.

Finally, posterior BPPV is the most common kind as the anatomy of the canals allows for collection of the crystals in the lowest part of the ear. In addition, neither rolling over nor lying down and getting up again will cause the crystals to empty out. The main treatment for this condition is the “particle repositioning maneuver” or Epley maneuver.

If you are having symptoms which don’t fit the norm make sure you discuss them with your own physician.

Until recently very few people knew about Mal de Debarquement syndrome. This syndrome can occur after any type of travel. The best analogy is sea sickness. When you first step onto a boat you might feel sea sick due to the constant motion of the boat. After a few days you get used to it and the sensation goes away. However, the same can happen when you get off the boat. The land may feel like it is moving. Anyone who has used roller skates, skis or ice skates can attest to how strange it feels after a few hours of skating or skiing and then returning to your street shoes. The same is true after getting off a boat. It may take hours to weeks to get used to land. In some people this adjustment never happens and they feel sea sick on land forever. We call this Mal de Debarquement, or sickness after disembarking.

Mal de Debarquement and BPPV can be differentiated in a couple of ways.

1)BPPV is positional in onset meaning that it will not occur unless you move into a certain position.
2)BPPV is also short lived rather than continuous. Mal de Debarquement syndrome should be continuous.
3)Mal de Debarquement can occur, and perhaps be worse, when stationary. It is the sensation of motion where there is no actual motion. This is different than BPPV which is the sensation of spinning (either you spinning or the world spinning around you)

The Epley maneuver or devices which assist with the treatment maneuver only work with BPPV. That is not to say that you cannot have both, but we always suggest you see your own doctor and get a diagnosis of BPPV prior to using any treatment method.