Dizziness Worse After the Epley? 5 Signs it isn’t BPPV
If your dizziness got worse after the Epley, you’re not alone and it often means you’re not dealing with simple BPPV. Over 35% of adults over the age of 40 have experienced vertigo in the United States according to the Vestibular Disorders Association. With such high prevalence, you would think that our health care system is better equipped to address the current dizziness epidemic. But instead what we see is blanket advice to use the Epley maneuver for all forms of dizziness and vertigo. While it can be effective when used appropriately, the Epley maneuver is hardly a cure-all.
The term vertigo often gets equated to a condition called benign paroxysmal positional vertigo (BPPV) but this is incorrect. Vertigo is a symptom and not a disorder. Vertigo can be loosely translated as an illusory sense of movement of either yourself or your surroundings when in reality there is none. There are over 25 different vestibular disorders that can create vertigo and the Epley only treats one. The maneuver can be highly provocative so dizziness worse after the Epley is a common complaint, especially in the presence of another vestibular disorder.
What the Epley Maneuver Actually Does
The Epley maneuver is a treatment technique for BPPV, specifically posterior canal BPPV. To truly understand how it works we first have to go over some inner ear anatomy.
Your inner ear balance organs are collectively known as a labyrinth. They’re composed of a sophisticated set of structures that relay information to your brain about where your head is located in space. You can think of them as a set of gyroscopes on either side of your head that detects head movement relative to gravity.
For BPPV and the Epley, we are primarily concerned about structures known as the utricle and semicirculars canal as illustrated in the image to the left.
The semicircular canals are filled with fluid known as endolymph. When you turn your head, the fluid in the canals move which is how your body detects rotational head movement.
This explains why people get dizzy after spinning in circles. The continuous spinning causes the fluid to move and pick up inertia. So when you suddenly stop spinning, the fluid is still moving even though your body is still. And the result is a vertigo.
Now the utricle is connected to the canals. There are calcium carbonate crystals, known as otoconia, that sit in the utricle. For reasons we still don’t quite understand, otoconia can get dislodged from the utricle and end up in a canal. The crystals in the canal cause excessive movement of the fluid with head motion and is the pathological basis for BPPV.
BPPV is characterized by brief intense episodes of vertigo that are correlated with head movement. Although it can feel highly distressing, treatment is relatively simple. To solve the problem, we move the head through a series of positions to direct the otoconia through the canal back into the utricle. This is the basis for the Epley maneuver.
There are three canals in each ear, as illustrated to the left. Posterior, horizontal, and anterior. What’s critical to understand is that the Epley maneuver only treats the posterior canal. It is not appropriate for the other canals. To make matters more complicated, there are even subsets of BPPV within each canal alone that involve more complex maneuvers. Further, there are other vertiginous disorders that have nothing to do with BPPV.
Beyond BPPV: A Comprehensive List of Vestibular Disorders
Now let’s zoom out a little and talk about the vestibular system as a whole. A person’s sense of balance is not reliant on the labyrinths alone. In simple terms, the labyrinths detect head motion and relays that information to the brain. The brain then takes that information and integrates it with other sensory systems of the body to produce your sense of balance.
Dizziness and vertigo are typically caused by disruptions within the system. If symptoms are due to faulty processing of labyrinthian information at the brain, then the subject is said to have a central vestibular disorder. Examples include:
- Vestibular Migraine: Episodic dizziness or vertigo often accompanied by symptoms such as headache and light or sound sensitivity.
- Persistent Postural Perceptual Dizziness (PPPD): persistent dizziness often described as a sense of rocking or swaying and poor tolerance to visually complex environments.
- Mal de Debarquement Syndrome: characterized by persistent dizziness symptoms usually after some form of travel.
- Concussion: dizziness or vertigo after sustaining some kind of head trauma.
Disorders of the inner ear, such as BPPV, reflect a dysfunctional labyrinth. The brain’s systems are intact but it’s receiving faulty information. What’s important is that there are multiple inner ear disorders, not just BPPV, that can cause vertigo. In these cases, the issue is known as a peripheral vestibular disorder. Examples include:
- Vestibular Neuritis: sudden vertigo that is present even without head movement due to sudden inflammation of the vestibular nerve.
- Labyrinthitis: similar to vestibular neuritis but accompanied by hearing loss
- Acoustic Neuroma: a noncancerous tumor on the vestibular nerve that causes dizziness, hearing loss, and tinnitus
- Superior Canal Dehiscence Syndrome: small hole in the labyrinth that causes sound or pressure induced dizziness
- Meniere’s Disease: an inflammatory condition that causes sudden fluid build up in the ear causing vertigo, hearing loss, and ear fullness.
The aforementioned disorders are what we see commonly in vestibular clinics although it is not an all-inclusive list. As you can see, each disorder is characterized by its own unique features different from those of BPPV. Examining for these other signs can help clue us in into what exactly is going on.
5 Signs it's not Actually BPPV
Here are five signs your dizziness may not actually be BPPV:
1. Duration
BPPV is characterized by brief episodes of vertigo, lasting seconds to minutes. If symptoms are lasting for hours or even days then it probably isn’t BPPV.
2. Quality of Dizziness or Vertigo isn't Room Spinning
There are of course exceptions but generally vertigo due to BPPV is often described as a room spinning sensation. As mentioned earlier, vertigo is a symptom and can present with various forms. If your symptoms feel more like a rocking, swaying, or internal movement even then this points away from BPPV.
3. Symptoms are Present Without Changes in Position
The pathophysiology of BPPV makes it apparent that symptoms should be triggered by head movement. If there are symptoms present while the head is still, it likely is not positional vertigo.
4. You Have Hearing Changes
The balance and hearing organs of the inner ear are intricately tied together. BPPV however has no implications on hearing. If you experience hearing changes that can include hearing loss, fullness, or tinnitus then this points to other disorders such as Meniere’s or labyrinthitis.
5. You have Additional Symptoms
Symptoms of dizziness or vertigo don’t always occur in isolation. In fact, they can often be accompanied by:
- Headache or migraine history.
- Light/sound sensitivity
- Brain fog and fatigue
- Motion sensitivity
- Visual issues.
In the presence of these additional symptoms, we may have to consider central disorders such as vestibular migraine.
Dizziness Worse After the Epley: What to do Next
Given everything, I generally do not recommend people try the Epley on their own. Even if it is posterior canal BPPV, there can be complications that I’ve detailed in another article.
The Epley is very tempting because it suggests an easy solution to a distressing problem but it’s not always so simple. Disorders such as vestibular neuritis often requires a six-week treatment plan. Vestibular migraine is a lifelong condition that needs to be properly managed. And disorders like PPPD are often most responsive to 12 weeks of vestibular rehabilitation.
Although inconvenient, the best action is to seek professional help if you are dealing with dizziness or vertigo. Depending on the condition, interdisciplinary care between vestibular therapists, a physician, and others may be indicated. If your dizziness or vertigo is accompanied by one-sided weakness, slurred speech, or facial drooping that is a medical emergency that requires immediate attention as it could indicate a stroke. For new sudden hearing loss, I suggest an urgent visit with a local ENT so they can preserve as much hearing as possible.
Most vestibular disorder are highly responsive to vestibular rehabilitation, a specialized form of physical therapy that addresses dizziness and vertigo. Often considered the gold standard for many vestibular disorders, vestibular rehabilitation helps to achieve better long-term outcomes than medications or surgical interventions. Vertigo can be highly complex but with the right approach, recovery is possible.
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