stimuli include passing cars and falling snow) other diseases: (labyrinthitis, ménière's disease, and migraine, etc.) treatment repositioning maneuvers a number of maneuvers have been found to be effective including canalith repositioning procedures (crp) such as the epley maneuver, the half somersault maneuver (hsm), the semont maneuver, and to a lesser degree the non-crp brandt–daroff exercises. both the epley and the semont maneuvers are equally effective. the hsm can have better long-term success than the epley, is more comfortable to experience, and has less risk of causing subsequent horizontal canal bppv (h-bppv). none of these maneuvers addresses the presence of the particles (otoconia); rather it changes their location. the maneuvers aim to move these particles from some locations in the inner ear that cause symptoms such as vertigo and reposition them to where they do not cause these problems. these maneuvers are easily performed at home and online resources are available to patients. the epley maneuver is popular because it is designed to address posterior canal bppv (pc-bppv), which is caused by particles in the posterior semicircular canal, the most common cause of bppv. this might give the wrong impression that pc-bppv is the only kind of bppv. misdiagnosing which semicircular canal is affected, typically by confusing horizontal and diagonal nystagmus, or simply ignoring the identification of the affected canal, and then using the wrong treatment maneuver, regularly results in no cure. using the appropriate maneuver for the affected canal is essential. the maneuvers may be uncomfortable for the patient as they might induce strong vertigo and the patient might then resist performing them. though some treatments, such as the epley, are much more uncomfortable than others, such as the hsm. if the maneuver is not uncomfortable then it is possible the wrong maneuver has been selected by a misdiagnosis of the affected semicircular canal. all the maneuvers consist of a series of steps in which the head is held in a specific position, typically for 30 to 60 seconds until any nystagmus stops. movement from one position to the position of the next step has to be done fluently to give the particles enough momentum to move. a position has to be held until any nystagmus has completely resided, which indicates that the particles have stopped moving, before one proceeds to the next step. epley maneuver main article: epley maneuver the epley maneuver employs gravity to move the calcium crystal build-up from the posterior semicircular canal (resulting in diagonal nystagmus) that causes the condition. this maneuver can be performed during a clinic visit by health professionals, or taught to people to perform at home, or both. postural restriction after the epley maneuver increases its effect somewhat. when practiced at home, the epley maneuver is more effective than the semont maneuver. an effective repositioning treatment for posterior canal bppv is the therapist-performed epley combined with home-practiced epley maneuvers. although follow-up by using home-practiced hsm instead of epley has better long-term success, with less discomfort, and less risk of causing subsequent horizontal canal bppv (h-bppv). devices such as the dizzyfix can help users conduct the epley maneuver at home, and are available for the treatment of bppv. half somersault maneuver the half somersault maneuver (hsm) is a patient-performed alternative to the epley for posterior canal bppv (pc-bppv) like the epley, it uses gravity to move the calcium crystal build-up from the posterior semicircular canal that causes the condition. compared to the epley, hsm has better long-term success, with less discomfort, and less risk of causing subsequent horizontal canal bppv (h-bppv). lempert maneuver or roll maneuver for the lateral (horizontal) canal, resulting in horizontal nystagmus, the lempert maneuver has been used for productive results. it is unusual for the lateral canal to respond to the canalith repositioning procedure used for the posterior canal bppv. treatment is therefore geared toward moving the canalith from the lateral canal into the vestibule. the roll maneuver or its variations are used, and involve rolling the person 360 degrees in a series of steps to reposition the particles. this maneuver is generally performed by a trained clinician who begins seated at the head of the examination table with the person supine there are four stages, each a minute apart, and at the third position the horizontal canal is oriented in a vertical position with the person's neck flexed and on forearm and elbows. when all four stages are completed, the head roll test is repeated, and if negative, treatment ceases. deep head hanging maneuver for the superior ( also called anterior ) semicircular canal, resulting in vertical nystagmus, the deep head hanging maneuver is used. the patient lays down on their back on a bed with their head overhanging the bed. in the first step the head is turned as backward (hanging) as possible. in the following step, the patient remains lying but lifts their head with the chin close to the chest. in the last step, the patient sits upright with the head in the normal position. before going to the next step, one has to wait until the nystagmus fully resides ( typical 30 to 60 seconds ) and progression from one step to the next has to happen in a fluid movement. semont maneuver the semont maneuver has a cure rate of 90.3%. it is performed as follows: the person is seated on a treatment table with their legs hanging off the side of the table. the therapist then turns the person's head 45 degrees toward the unaffected side. the therapist then quickly tilts the person so they are lying on the affected side. the head position is maintained, so their head is turned up 45 degrees. this position is maintained for 3 minutes. the purpose is to allow the debris to move to the apex of the semicircular duct. the person is then quickly moved so they are lying on the unaffected side with their head in the same position (now facing downward 45 degrees). this position is also held for 3 minutes. the purpose of this position is to allow the debris to move toward the exit of the semicircular duct. finally, the person is slowly brought back to an upright seated position. the debris should then fall into the utricle of the canal and the symptoms of vertigo should decrease or end completely. some people will only need one treatment, but others may need multiple treatments, depending on the severity of their bppv. in the semont maneuver, as with the epley maneuver, people are able to achieve canalith repositioning by themselves. brandt–daroff exercises the brandt–daroff exercises may be prescribed by the clinician as a home treatment method, usually in conjunction with particle-repositioning maneuvers or in lieu of the particle-repositioning maneuver. the exercise is a form of habituation exercise, designed to allow the person to become accustomed to the position that causes the vertigo symptoms. the brandt–daroff exercises are performed in a similar fashion to the semont maneuver; however, as the person rolls onto the unaffected side, the head is rotated toward the affected side. the exercise is typically performed 3 times a day with 5–10 repetitions each time, until symptoms of vertigo have resolved for at least 2 days. medications medical treatment with anti-vertigo medications may be considered in acute, severe exacerbation of bppv, but in most cases are not indicated. these primarily include drugs of the antihistamine and anticholinergic class, such as meclizine and hyoscine butylbromide (scopolamine), respectively. the medical management of vestibular syndromes has become increasingly popular over the last decade, and numerous novel drug therapies (including existing drugs with new indications) have emerged for the treatment of vertigo/dizziness syndromes. these drugs vary considerably in their mechanisms of action, with many of them being receptor- or ion channel-specific. among them are betahistine or dexamethasone/gentamicin for the treatment of ménière's disease, carbamazepine/oxcarbazepine for the treatment of paroxysmal dysarthria and ataxia in multiple sclerosis, metoprolol/topiramate or valproic acid/tricyclic antidepressant for the treatment of vestibular migraine, and 4-aminopyridine for the treatment of episodic ataxia type 2 and both downbeat and upbeat nystagmus. these drug therapies offer symptomatic treatment, and do not affect the disease process or resolution rate. medications may be used to suppress symptoms during the positioning maneuvers if the person's symptoms are severe and intolerable. more dose-specific studies are required, however, in order to determine the most effective drug(s) for both acute symptom relief and long-term remission of the condition. surgery surgical treatments, such as a semi-circular canal occlusion, exist for severe and persistent cases that fail vestibular rehabilitation (including particle repositioning and habituation therapy). as they carry the same risks as any neurosurgical procedure, they are reserved as last resorts.