From the Guidelines
Yes, a patient with benign paroxysmal positional vertigo (BPPV) can have a negative Dix-Hallpike test. While the Dix-Hallpike maneuver is considered the gold standard diagnostic test for posterior canal BPPV, its accuracy may vary between specialty and nonspecialty clinicians, with a reported sensitivity of 82% and specificity of 71% for the Dix-Hallpike maneuvers in posterior canal BPPV, primarily among specialty clinicians 1. Several factors can contribute to a negative test result in a patient who actually has BPPV, including:
- The test may be performed incorrectly without proper head positioning or insufficient speed of movement
- Some patients may have fatigability of symptoms, where repeated testing reduces or eliminates the vertigo response
- BPPV affecting the horizontal or anterior semicircular canals rather than the more common posterior canal may not be detected by the standard Dix-Hallpike test; these variants require different diagnostic maneuvers such as the supine roll test for horizontal canal BPPV
- Certain medications like vestibular suppressants can mask symptoms during testing If BPPV is still suspected despite a negative Dix-Hallpike test, clinicians should consider repeating the test at a different time, performing alternative positional tests, or referring to a vestibular specialist for more comprehensive evaluation, as the negative predictive value of the Dix-Hallpike maneuver is relatively low, at 52% in the primary care setting 1.
From the Research
Benign Paroxysmal Positional Vertigo and the Dix-Hallpike Test
- The Dix-Hallpike test is a diagnostic tool used to identify benign paroxysmal positional vertigo (BPPV) 2.
- A patient with BPPV can have a negative Dix-Hallpike test, as the test's sensitivity is estimated to be around 79% 2.
- The specificity of the Dix-Hallpike test is estimated to be around 75%, which means that some patients with BPPV may test negative 2.
Factors Influencing Dix-Hallpike Test Results
- The number of maneuvers needed to achieve a negative Dix-Hallpike test can vary depending on the etiology of BPPV 3.
- Repeating the Dix-Hallpike test can increase the diagnostic success in BPPV, as some patients may test negative initially but positive after repeated testing 4, 5.
- Failure to repeat the tests of the posterior semicircular canals may result in a falsely negative test 5.
Diagnostic Value of Repeated Dix-Hallpike Maneuvers
- Performing the Dix-Hallpike maneuver sequentially one more time in patients with negative results can increase the diagnosis success in BPPV 4.
- The diagnostic value of repeated Dix-Hallpike maneuvers is supported by studies that show a significant difference between pre- and post-treatment scores in patients with BPPV 4.
- Repeated testing can reduce the likelihood of patients undergoing extra testing or other consequences of misdiagnosis 5.