What is the role of the Dix-Hallpike (Dix-Hallpike maneuver) in diagnosing and treating benign paroxysmal positional vertigo (BPPV)?

The Role of the Dix-Hallpike Maneuver in BPPV

The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior canal benign paroxysmal positional vertigo (BPPV) and should be performed in all patients with suspected positional vertigo to confirm the diagnosis before treatment. 1

Diagnostic Role

• The Dix-Hallpike maneuver confirms posterior canal BPPV when it elicits vertigo associated with characteristic torsional, upbeating nystagmus with a latency period between the completion of the maneuver and symptom onset 1, 2
• The test has a sensitivity of 82% and specificity of 71% for posterior canal BPPV among specialty clinicians, with a positive predictive value of 83% but a lower negative predictive value of 52% in primary care settings 1, 2
• A negative Dix-Hallpike maneuver does not necessarily rule out BPPV; repeating the test at the same or a separate visit may be necessary to avoid false-negative results 1, 3
• If the Dix-Hallpike test is negative or shows horizontal nystagmus in a patient with symptoms compatible with BPPV, a supine roll test should be performed to assess for lateral canal BPPV, which accounts for approximately 10-15% of BPPV cases 1, 4

Proper Technique

• Before beginning, counsel the patient that the maneuver may provoke sudden intense vertigo and possibly nausea, which typically subsides within 60 seconds 2
• Position the patient so that when placed supine, their head can "hang" with support off the posterior edge of the examination table by about 20 degrees 2
• Steps for performing the Dix-Hallpike maneuver: 1, 2
  1. Stand at the patient's side and rotate their head 45° to the side being tested
  2. Quickly move the patient from sitting to supine with the head extended 20° below horizontal
  3. Observe for nystagmus and ask about vertigo symptoms
  4. After symptoms subside, return the patient to sitting position
  5. Repeat for the opposite side if the first side is negative

Diagnostic Criteria for Posterior Canal BPPV

• Positive Dix-Hallpike test showing: 1, 2
  • Vertigo associated with torsional, upbeating nystagmus
  • Latency period between maneuver completion and symptom onset
  • Nystagmus and vertigo increasing and resolving within 60 seconds

Precautions and Contraindications

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

Role in Treatment

• The Dix-Hallpike maneuver helps identify the affected ear, which is critical for selecting the appropriate treatment maneuver 5, 6
• After diagnosis, canalith repositioning procedures (such as the Epley maneuver) can be performed, with success rates of 90.7% after the initial maneuver and up to 96% after a second attempt 6
• The Dix-Hallpike test should be repeated after treatment to confirm resolution of symptoms and nystagmus 6, 3

Special Considerations

• In some cases, the Dix-Hallpike test may be positive bilaterally, especially after head trauma 1, 7
• Factors affecting diagnostic accuracy include speed of head movements, time of day, and angle of the occipital plane during the maneuver 1, 8
• If initial testing is negative but clinical suspicion remains high, repeating the Dix-Hallpike test after testing the horizontal canals may improve diagnostic yield, as this sequence can allow canaliths to collect in a position that makes subsequent testing positive 8, 3