Assessment Measures for Diagnosing Vertigo
The Dix-Hallpike maneuver is the most important diagnostic test for vertigo and should be performed in all patients with suspected vertigo to diagnose posterior semicircular canal BPPV, the most common cause. 1
Key Diagnostic Maneuvers
Dix-Hallpike Maneuver (for Posterior Canal BPPV)
- Performed by bringing the patient from upright to supine position with head turned 45 degrees to one side and neck extended 20 degrees
- Positive test shows:
- Vertigo with characteristic nystagmus
- Latency period (typically 5-20 seconds) between maneuver completion and onset of symptoms
- Vertigo and nystagmus that increase and resolve within 60 seconds
Supine Roll Test (for Lateral Canal BPPV)
- Used when Dix-Hallpike is negative but BPPV is still suspected
- Performed by quickly turning the patient's head from one side to the other while supine
- Observe for horizontal nystagmus
History Taking for Vertigo Assessment
Focus on these specific elements:
- Timing and duration of vertigo episodes
- Provoking factors (especially head position changes)
- Associated symptoms:
- Auditory symptoms (hearing loss, tinnitus, aural fullness) suggesting Ménière's disease
- Headache, visual aura, light sensitivity suggesting vestibular migraine
- Neurological symptoms suggesting central causes
When to Consider Additional Testing
Radiographic imaging and vestibular testing should NOT be routinely obtained in patients diagnosed with BPPV unless the diagnosis is uncertain or there are additional neurological symptoms atypical for BPPV. 1
Consider additional testing when:
- Dix-Hallpike or supine roll tests are inconclusive
- Symptoms are atypical for BPPV
- Treatment failure occurs after 2-3 properly performed repositioning maneuvers
- Neurological symptoms are present:
- Abnormal cranial nerve findings
- Visual disturbances
- Severe headache
- Gait, speech, or autonomic dysfunction
Red Flags Requiring Further Investigation
- Nystagmus that does not lessen when the patient focuses (suggests central cause)
- Falls or drop attacks during vertigo episodes
- Persistent symptoms despite appropriate treatment
- Hearing loss (especially unilateral)
- New-onset vertigo in patients with risk factors for cerebrovascular disease
Common Pitfalls to Avoid
- Failing to perform the Dix-Hallpike maneuver properly (most common diagnostic error)
- Ordering unnecessary imaging or vestibular testing for typical BPPV
- Missing central causes of vertigo by not performing a thorough neurological examination
- Not reassessing treatment failures (which may indicate persistent BPPV or an alternative diagnosis)
By following this systematic approach to vertigo assessment with emphasis on proper positioning maneuvers, clinicians can accurately diagnose most cases of vertigo without unnecessary testing, leading to improved patient outcomes and reduced healthcare costs.