What is the Dix-Hallpike (Dix-Hallpike test) maneuver?

The Dix-Hallpike Maneuver: Gold Standard Test for Posterior Canal BPPV

The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior canal benign paroxysmal positional vertigo (BPPV), involving a specific sequence of head positioning movements to elicit characteristic nystagmus. 1

Procedure for Performing the Dix-Hallpike Maneuver

Preparation

• Before beginning, counsel the patient about the upcoming movements and warn that they may provoke sudden intense vertigo and possibly nausea, which will typically subside within 60 seconds 1
• Position the patient so that when placed in the supine position, their head can "hang" with support off the posterior edge of the examination table by about 20 degrees 1
• Ensure you can safely support the patient's head throughout the maneuver 1

Step-by-Step Technique

1. Begin with the patient in an upright seated position 1
2. Stand at the patient's right side and rotate their head 45 degrees to the right to align the right posterior semicircular canal with the sagittal plane of the body 1
3. Quickly move the patient from the seated position to a supine position with the head hanging about 20 degrees below horizontal 1, 2
4. Observe for:
   • Latency period (typically 5-20 seconds) before onset of nystagmus 1
   • Characteristic torsional, upbeating nystagmus 1
   • Subjective vertigo reported by the patient 1
   • Nystagmus that increases and then resolves within 60 seconds 1
5. After resolution of symptoms and nystagmus, slowly return the patient to the upright position (a reversal of nystagmus may be observed during this return) 1
6. Repeat the entire procedure for the left side to complete the test 1

Diagnostic Criteria for Posterior Canal BPPV

• Vertigo associated with torsional (rotatory), upbeating nystagmus provoked by the Dix-Hallpike test 1
• Latency period between completion of the maneuver and onset of vertigo/nystagmus 1
• Provoked vertigo and nystagmus increase and resolve within 60 seconds from onset 1

Diagnostic Accuracy

• Sensitivity of 82% and specificity of 71% for posterior canal BPPV among specialty clinicians 1
• In primary care settings, positive predictive value of 83% but lower negative predictive value of 52% 1
• A negative test does not rule out BPPV; repeating the test at a separate visit may be necessary 1, 3

Important Considerations

• Factors affecting diagnostic accuracy include speed of head movements, time of day, and angle of the occipital plane 1
• The test must be performed bilaterally to determine which ear is involved 1
• In some cases, the test may be positive bilaterally, especially after head trauma 1
• If initial testing is negative, consider repeating the Dix-Hallpike test after testing for horizontal canal BPPV, as this sequence may allow canaliths to collect and produce a positive test on repeat examination 2

Precautions and Contraindications

• Exercise caution in patients with:
  • Significant vascular disease (risk of stroke) 1
  • Cervical stenosis or limited cervical range of motion 1
  • Severe kyphoscoliosis 1
  • Down syndrome 1
  • Severe rheumatoid arthritis 1
  • Cervical radiculopathies 1
  • Ankylosing spondylitis 1
  • Spinal cord injuries 1
  • Morbid obesity (may require additional assistance) 1
• For patients with physical limitations, special tilting examination tables may allow safe performance of the maneuver 1

When to Consider Alternative Testing

• If the Dix-Hallpike test exhibits horizontal or no nystagmus in a patient with symptoms compatible with BPPV, perform a supine roll test to assess for lateral semicircular canal BPPV 1
• Lateral canal BPPV accounts for approximately 10-15% of BPPV cases 1