Epley, Semont or Brandt-Daroff Exercises? Which should I choose?

Recently we were asked, “Which is best, the Epley, Semont or Brandt-Daroff for the treatment of 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.


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.

33 Responses

  1. Cynthia

    I had an Epley manuever performed by my pt for my BPPV…it put me in horrific vertigo that wouldn’t stop….took days to calm down…..a week later I was still dizzy and not able to sleep lying down. Did Brandt-Daroff 5x on each side and it cleared it. So, Brandt-Daroff is useful in certain conditions.

  2. MohammadBold

    I have checked your website and i’ve found some duplicate content,
    that’s why you don’t rank high in google’s search results, but there is
    a tool that can help you to create 100% unique articles,
    search for: SSundee advices unlimited content
    for your blog

  3. Barbara Herrington

    I am having vertigo episodes similar to those cited here, along with the hot flashes, nausea, and anxiety. My doctor prescribed meclizine (over-the-counter Dramamine, the less sleepy type); one 12 mg dose an hour before bedtime really blunts the nausea and anxiety. Also makes it easier to address the vertigo through the various physical maneuvers. I, too, start out sleeping in a chair at night and later move to stacked pillows.

  4. Manish

    Hi m manish from india. My mother is suffering right side BPPV from last 3 years . She also have a stiffness in lower neck. Is there any permanent solution of it ??

  5. Susanne

    My husband had a couple of dizzy episodes for a couple of days, I persuaded him to see our GP who told him it was vertigo. He prescribed sea sickness tablets to take for 2 weeks. Our friend who had been staying with us and upon returning home reported she had had dizzy spells and her GP had prescribed Brandt Daroff exercises which seemed to do the trick.

  6. Clearwater Clinical

    Hmm, sorry to hear about the “pain in the neck”. That sounds muscular,…I assume you have spoken with your GP? What I can tell you is that vestibular problems do not cause neck pain (not directly at least). Interestingly, there is some evidence that neck problems can cause a type of disequilibrium (off balance feeling) called Cervical Vertigo.

  7. sandy

    I was so amazed by the results of the epely maneuver for taking care of the horrible vertigo but I was left with a neck problem caused by attempting the last days exercise alone with out anyone helping support my head. now I have a stiff neck and pain on the lower right side of my neck and its been about two months. help

  8. Clearwater Clinical

    Thanks for the comment. I would like to recommend reading the new AAO-HNS guidelines on the treatment of BPPV. They clearly state that the preferred treatment is the Epley (often called the canalith repositioning maneuver or CRP).

    “The purpose of this statement is to provide evidence for and promote the specific use of CRPs as the initial treatment to resolve symptoms and disability secondary to posterior and lateral canal BPPV. There is high-quality and compelling evidence that patients diagnosed with posterior and lateral semicircular canal BPPV should be offered expeditious treatment with CRP. These are specific and distinct from habituation/movement exercises, such as the Cawthorne-Cooksey exercises or Brandt-Daroff exercises. Treatment of BPPV with CRPs consistently eliminates the disabling vertigo and can also improve quality of life and reduce the risk of falling.”

    So yes there are other maneuver. The CRP is the best. You can do it yourself at home or with home treatment devices like the DizzyFIX

  9. Clearwater Clinical

    If you have BPPV you don’t really need an MRI. However, it sounds like the ENT isn’t too sure it is BPPV since you didn’t have a positive test. The AAO-HNS has just released new guidance on the treatment of BPPV which can be found here: AAO-HNS BPPV Guidelines . They do not suggest an MRI. However, I cannot speak to your specific situation. “exercises” usually refer to Brandt-Daroff Exercises which are ok, but not as effective as the Epley maneuver – this fact is also well documented in the above guidelines. If you do have BPPV – ensure you have the right diagnosis – then seek someone/someway to do the Epley.

  10. Clearwater Clinical

    Interesting advice, and you might actually be correct. The posterior ear canal (the one that BPPV comes from) is shaped in such a way that it is maximally stimulated during an attack when you are on your back with your head extended about 30 degree and tilted to the side by 45 degrees. This is something you might accidentally do when lying down. If you keep you neck flexed by about 30 degrees instead of extended by 30 degrees you might stop the attack, also by lying flat down instead of onto you side you might also reduce the attack. Finally, if you do this all slowly, even if you do get an attack, it will be much less “intense” than if you threw yourself into bed hoping to avoid the attack.

    So yes – Lie down slowly, avoid turning you head, use an extra pillow will avoid stimulating active BPPV. However, rather than sleeping in funny positions it is usually better to just do the Epley maneuver and get rid of it altogether.

  11. Clearwater Clinical

    Interesting question. Yes and no. If you are not sure that you have BPPV then I wouldn’t bother with the Epley maneuver. However, if you have a diagnosis it is possible to have BPPV in both ears which makes it difficult to tell which side to start with. Only about 10% of people are in this situation. Generally speaking it is best to treat only one side at a time. You do this by doing the Epley on one side for 1 week and then on the other side for the next week. Often you can tell when you are successful on one side as you will stop getting dizzy during the maneuver. Best of luck.

  12. Jane Howell

    Can Epley maneuver be used if not sure which ear affected, or both are?

  13. Sally Pearce

    I have just had two episodes of BPPV, three days ago. The first episode, when I rolled onto my left side, the room started spinning and en-suite light began strobe flashing. Disturbed, I then rolled onto my R side and the entire bed tipped on its side and I yelled out ( waking my husband) and grabbed the mattress thinking I was going to tumble to the floor. The following day I felt peculiar, but not too bad and I had no further attacks of dizziness but that night, I had wave after wave of the spinning sensations every time I rolled over. By keeping my eyes shut tight, ( as seeing is believing) I only had to contend with the feeling my head was spinning on my neck and didn’t have to face the additional fear of plummeting to my death.
    On day two, I saw a GP who diagnosed a viral infection of my inner ear and said it should right itself in two weeks.
    However my sister has suffered BPPV for twenty years and she advised me to do the Epley maneuver. This I did last night (third night from initial episode) and although everything spun around during the first cycle of the exercises ( had to grab my husband’s hand) the second and third cycle wasn’t as bad.
    As I was still very reluctant to lie down and try to go to sleep I decided to rest my head on two pillows rather than one ( so my head would be more elevated) and every time I rolled over, I broke the roll by first rolling onto my back, staying there for about 60 seconds before continuing the roll onto the other side.
    And not one dizzy attack, all night.
    So for those sufferers who would rather try to sleep standing against a wall than having to lie down in a bed , I suggest trying an extra pillow so the head is more elevated and breaking each roll by rolling onto your back first, staying there for a short time before continuing your roll onto your other side.

  14. Bonne

    To answer your question about my diagnosis…..my pcp said labrynthitis. I saw an ENT 10 days later and he said he thought it was “crystals” even though I did not have a positive Epley test. So he ordered the excercises and an MRI.

  15. Bonne

    Hi. It’s 25 days into the aftermath of vertigo that started typically upon awakening. The spinning sensation lasted about 20 seconds. When I got up and around I was particularly sensitive to tilting my head to the right and very much so when I tilted my head up and down. Walking in stares and outside resulted in a “jarring” feeling in my head with some dizziness. Presently I just started the Brandt adrift that my ENT prescribed. Mainly I feel a left to right dizziness when I raise myself up to a seated position. It lasts 10 seconds. I’d like to know if this is to be expected. Any other excercise suggestions for this type of response?

  16. Clearwater Clinical

    Thanks for sharing your story. It isn’t clear from your description that you have BPPV. Is this what your doctor told you? If you do have BPPV then yes sometimes the Brandt-Daroff exercises help but to be honest they are mostly ineffective. The evidence suggests that the Epley maneuver is much more effective at eliminating BPPV. You can do this maneuver at home with the DizzyFIX if you like or see and ENT doctor or a vestibular physiotherapist to get it done. Medication helps a bit, though only by masking the symptoms, so use it if you need it but it isn’t treating the vertigo, a better way is to do the Epley maneuver. Best of luck

  17. Robyn Bartlett

    i suffer from intermittent vertigo which can make me feel really spacey and weird for several hours in the morning upon arising from bed. My doctor gave me information to this site and I plan to start the Brandt-Daroff exercises which will hopefully help. He also prescribed me Prochlorperazine Maleate which is supposed to help with symptoms. I never feel like vomitting just suffer from the dizziness. Do you think that this medication helps relieve these symptoms?

  18. Lorraine Measor

    I have vertigo when I crank my neck to the right for example when I am backing the car out of the garage…….very annoying! What can i do!

  19. Clearwater Clinical

    Thanks for the comments. Sadly it is true that you get a lot of different advice from different people. There are of course many different types of dizziness. The truth about BPPV is that no medications actually treat it. Some may mask the symptoms but none are as effective as the particle repositioning maneuver (epley maneuver). Caffeine and smoking can indeed exacerbate the experience of BPPV but don’t really cause it. Good luck!

  20. Diane

    Hi, I have suffered from this condition since 1990. I have had regular bouts over the years, some worse than others- some lasting days, weeks or months. Been to see various Drs.including ENT have had conflicting diagnosis & many different medications all to no avail. Most recently I was told to avoid caffeine & smoking. I am so grateful I found this site & intend asking my doctor about physio, semont & epley manoeuvres as this has had a huge impact on my quality of life..( was told the hot flashes were unrelated & ‘just hormones ‘)I will let you know how I get on Thankyou for all the helpful information.

  21. Clearwater Clinical

    Thanks for sharing your experience. Sleeping upright certainly avoids putting yourself in the stimulating position and thus avoids exacerbations. Many people are not able to sleep well sitting up, however. BPPV is by nature paroxysmal and will come and go. While the Semont and Epley have equal effectiveness when done by a professional they can be ineffective when done at home as it is difficult to be accurate when dizzy. You may find additional benefit by seeing a specialist of by using a home treatment device to ensure you perform the maneuvers correctly. BPPV is often recurrent so it may well come back – let us know how you do.

  22. Inger Grape

    I want to add to my comment above. After the Semont maneuver cured me, I was symptom-free for a year. Then I had a dental procedure done where I was tilted almost backwards and towards my “bad” side; I could feel something that made me think, uh-oh. Surely enough, slowly the dizzy spells in the morning started coming back, and with it the total lack of sleep, with never-ending hot flashes during the night. It got every bit as bad as before, and I googled and found a modified Semont maneuver that involves lying down 3 min. on ea. side and no sitting up still for 10 min. afterwards.

    At first it helped a lot, but then it didn’t seem to so much. The last bad night was so bad that I was unable to even complete a Semont maneuver, as one or both of the positions was unbearably uncomfortable. Then the next day I noticed how well I slept in the passenger seat of our car on a long drive, so I spent the first part of that night sitting upright in my car, in a sleeping bag with headphones and a sleep mask. That was the road to my recovery. The next 3 nights I have started each night by sitting bolt upright on my sofa (I need to modify my neck collar for my short neck) and sleeping like that for an hour or two, then segueing into my bed, with a big berm of pillows to prop me up at a slant, which feels more comfortable (but it never actually helped before). Doing this, all of a sudden I was able to sleep undisturbed for 6 hours.

    After the first 3 nights of starting my sleep upright, I woke up feeling completely, 100% normal, for the 1st time in months. Today I’m on day 3 of feeling 100% normal, and I have not have had to do any positional maneuvers. The brief feeling of having the ground drop from under me every time I would bend my head forward is completely gone too. I am cautiously optimistic that I have found the key to my puzzle for now.

  23. Clearwater Clinical

    Thanks for your questions. Yes there are different versions of the Epley. Some work, some don’t it really does depend on exactly what you do. The DizzyFIX device guides you through the standard maneuvers. You can also ready about why maneuvers sometimes don’t work here – http://clearwaterclinical.com/blog/2009/04/epley-maneuver-how-many-times-should-it-take.html

    It is safe to do the maneuver on an incline bench. Usually this is done for people who don’t have very good neck range of motion.

    Brandt-Daroff maneuvers for BPPV, in my view, are outdated as there are much better maneuvers which work. The key is to know what the diagnosis is. If you don’t have BPPV then no maneuvers will work.

    Thanks again for yor questions.

  24. Christopher

    I had BPPV about three years ago and was instantly cured by an ENT consultant. This time, having got BPPV after a heavy fall skiing, I did Brandt Daroff exercises for a week, as previously recommended. They achieved a little improvement but also a certain amount of nausea.

    Having read this article I switched to the Semont manoeuvre, which totally cured me in two days. I am 75 years of age.

    Thank you.

  25. Christy

    Thanks for the opportunity to get additional information about BPPV. I was diagnosed with left BPPV in early Nov 13. I had the Epley maneuver performed at my doctor’s office on a Friday followed by 72 hours of no head movement and sleeping semi-vertically. The following Friday my Doctor repeated the Epley maneuver followed by 48 hours of no head movement and sleeping semi-vertically. Unfortunately the procedures did not work so he recommended physical therapy. The physical therapist did a different version of Epley and also recommended the Brandt-Daroff maneuver at home which I have been performing for 10 days. I still have symptoms. PT is going to try the Epley maneuver next week on an incline bench. I am not comfortable with this decision and want to know if this is safe. Yesterday when I had the Epley performed my shoulders were extended beyond the table and caused quite a lot of pain in my neck. I guess my questions are: 1) Are the Brandt-Daroff maneuver exercises outdated? 2) Is it effective to do the Epley maneuver on an incline bench? Thank you so much for your time and information.

  26. Clearwater Clinical

    Log rolls work very well with horizontal canal BPPV. Unfortunately, the vertigo is worse and some people can vomit during the maneuver. This is quite unusual with p-BPPV.

  27. Clearwater Clinical

    This is not correct. Medication will not impact the outcome of BPPV (for good or bad). The treatment is the Epley or the Semont maneuver. The Brandt Daroff exercises are simply designed for you to get used to the vertigo (why do this when you can get rid of it). It is possible that with Labyrinthitis (not with BPPV) medication may slow recovery by inhibiting your re-acclimation to your new state.

  28. Clearwater Clinical

    People describe the sensation of “dizziness” quite differently. For most it is spinning but certainly some people do describe “waves” or other terms. The real indicator is the positional nature of it and the impact on the eyes (Nystagmus). Semont and Epley are essentially equivalent when done correctly.

  29. Tanke

    for sure this Epley, Semont or Brandt-Daroff Exercises? Which should I choose? Why am I dizzy? Is it BPPV? is so excellent to read through

  30. Inger Grape

    The Semont maneuver, as shown by U of Michigan on YouTube, cured me. I did it every morning for about 2 weeks and the dizzy spells gradually subsided and then disappeared completely.

    Reclining was the position that got me in trouble; the “ear rocks” would severely disturb my balance sensors all night, not causing dizziness during the night but causing constant hot flashes and “restless-body syndrome,” a sensation of being tilted backwards (even when sleeping propped up), and complete lack of sleep. Then when I would get up, I’d experience a dozen or two dizzy spells till it subsided for the day, till the next morning. (Initially I thought the dizzy spells were brought on by the lack of sleep.)

    The Epley maneuver gave me 2 days of relief initially, which is how I could tell what it was (I diagnosed it, and the doc did not disagree). But then it didn’t seem to help much. One scary day I had a dizzy spell while driving, and that evening I tried the Semont maneuver, after one commentator said it helped him better than Epley.

    Significantly, the Semont maneuver started repairing my sleep from the first time I tried it, even before the dizzy spells disappeared. This was even when I did it starting from the wrong a side. (When I switched sides after a few days, it started working much better.) Now, several months later, I have had no more dizzy spells (and with them went the hot flashes and “restless-body syndrome”), the fear has almost left me, and my sleep is better than it has been in decades!

    Positional vertigo is epidemic (witness all the views, likes and comments on YouTube); as soon as I mention it, somebody is likely to say, “Oh, I have …” or “Oh, I know somebody ….” The approach of the medical community as a whole is deplorable (thank you for being the good guys!). Most doctors apparently are worse than no help! They’ll look everywhere else, scheduling MRIs, EKGs and all manner of other tests, then referrals and medications before they consider positional vertigo, the most common cause of dizzy spells! Is this purposeful? They are even trained to ask the wrong questions. There is no excuse for this. It is so common and easy to diagnose that instructional videos are all over YouTube, it was featured in an episode of the excellent British TV series “Doc Martin” (where the good doctor did the Epley maneuver, which all doctors should know to do) and I was able to diagnose it before my doctor! Among other things, positional vertigo does NOT have to have a spiraling component. The people I talked with had a similar experience of the dizzy spells that I had: No particular awareness of the room or me spinning or not; the feeling was more a sensation of complete chaos of awareness, where I would most certainly fall if I didn’t sit down, and even sitting down on a stool (or the toilet), I had to hold on for dear life. Sometimes when I would get up in the morning, the initial feeling wasn’t dizziness but rather as if I were a ship in high seas, with loose ballast rolling around–I was compelled to rock myself till “the ballast” settled.

  31. Cindy Chaney

    It is my understanding, based on what my doctor has explained, that the Brandt Daroff Exercise is used to create vertigo so that the brain is given multiple opportunities to detect imbalance and attempt to repair. If a person takes medication to stop the vertigo the brain is not given the opportunity to complete the repairing process.
    If the brain is given opportunities to detect the vertigo and attempts to repair – there is a chance that the vertigo will occur less and less naturally.
    If the brain is NOT given opportunities to detect the vertigo and attempt repair (when medication is used to stop vertigo and repair attempts) the patient will most likely have more and more occurrences of vertigo naturally.

  32. Dr.Sudiptarun Sen

    Iam a practising otolaryngologist. I titally agree with your approach. Excellent comparison. What is your experience with Log Roll in Horizontal canal BPPV?



Leave a Reply