What is the proper technique for performing the Dix-Hallpike (Dix-Hallpike maneuver) test?

Proper Technique for Performing the Dix-Hallpike Maneuver

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

Preparation

• Before beginning, counsel the patient that the maneuver may provoke sudden intense vertigo and possibly nausea, which typically subsides within 60 seconds 2, 1
• Position the patient so that when placed supine, their head can "hang" with support off the posterior edge of the examination table by approximately 20 degrees 2, 1
• Ensure you can safely support the patient's head throughout the entire maneuver without losing balance 2

Step-by-Step Procedure

1. Begin with the patient in an upright seated position 2
2. Stand at the patient's right side and rotate the patient's head 45 degrees to the right to align the right posterior semicircular canal with the sagittal plane of the body 2, 1
3. While maintaining the 45-degree head rotation, quickly move the patient from the seated position to a supine position with the head hanging approximately 20 degrees below horizontal 2, 1
4. Observe for nystagmus and ask about subjective vertigo 2
5. After symptoms subside (or after 1 minute if no symptoms occur), slowly return the patient to the seated position 2
6. Repeat the entire procedure (steps 1-5) for the left side, rotating the head 45 degrees to the left 2, 1

Diagnostic Criteria

• A positive test shows:
  • Latency period of 5-20 seconds (rarely up to 1 minute) between completion of the maneuver and onset of vertigo/nystagmus 2
  • Torsional (rotatory), upbeating nystagmus 1
  • Vertigo and nystagmus that increase and then resolve within 60 seconds from onset 2

Important Considerations

• The test must be performed bilaterally to determine which ear is involved 2, 1
• If initial testing is negative, consider repeating the maneuver, as this can significantly increase diagnostic yield 3, 4
• Factors affecting diagnostic accuracy include:
  • Speed of movements during the test 2
  • Time of day 2
  • Angle of the occipital plane during the maneuver 2

Precautions and Contraindications

• Exercise caution in patients with:
  • Significant vascular disease 2
  • Cervical stenosis or limited cervical range of motion 2
  • Severe kyphoscoliosis 2
  • Down syndrome 2
  • Severe rheumatoid arthritis 2
  • Cervical radiculopathies 2
  • Ankylosing spondylitis 2
  • Spinal cord injuries 2
  • Morbid obesity (may require additional assistance) 2
• For patients with physical limitations, special tilting examination tables may allow safe performance of the maneuver 2

Alternative Testing

• If the Dix-Hallpike test is negative but BPPV is still suspected, perform a supine roll test to assess for lateral (horizontal) canal BPPV 2, 1
• Consider using an expanded Dix-Hallpike maneuver with intermediate steps for suspected multi-canal BPPV 5

Diagnostic Accuracy

• Sensitivity: 82% and specificity: 71% among specialty clinicians 2
• Positive predictive value: 83% and negative predictive value: 52% in primary care settings 2
• A negative test does not rule out BPPV; consider repeating at a separate visit 2, 4