What is the recommended approach for testing and treating Benign Paroxysmal Positional Vertigo (BPPV)?

Testing for BPPV

Diagnose posterior canal BPPV using the Dix-Hallpike maneuver, which involves bringing the patient from upright to supine with the head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus and vertigo. 1

Diagnostic Approach for Posterior Canal BPPV (Most Common)

Perform the Dix-Hallpike maneuver as the gold standard test:

• Position the patient sitting upright, turn their head 45° toward the side being tested 2
• Quickly move them from sitting to supine with head extended 20° below horizontal with the affected ear down 1
• Repeat with the opposite ear down if the initial maneuver is negative 1

A positive test demonstrates:

• Brief latency period (few seconds) before onset of symptoms 2
• Torsional, upbeating nystagmus toward the affected (downward) ear 1
• Vertigo that accompanies the nystagmus 1
• Symptoms that increase then resolve within 60 seconds 2

Diagnostic Approach for Lateral Canal BPPV

If the Dix-Hallpike shows horizontal or no nystagmus but history is compatible with BPPV, perform the supine roll test: 1

• Position patient supine with head in neutral position 2
• Quickly rotate head 90° to one side, then the other 2
• Look for horizontal nystagmus during head rotation 2
• The side with stronger nystagmus typically indicates the affected ear 2

Key Clinical History Features

Two symptoms most strongly predict BPPV:

• Dizziness episodes lasting less than 60 seconds 2, 3
• Dizziness provoked by rolling over in bed (81% sensitivity) 3

Additional supportive history:

• Brief vertigo triggered by specific head position changes (looking up, bending forward) 2
• Patients often modify movements to avoid triggering symptoms 2
• Approximately 50% report subjective imbalance between episodes 2

What NOT to Do

Do not order neuroimaging in patients meeting diagnostic criteria for BPPV without additional neurologic signs or symptoms inconsistent with BPPV. 1

Do not order vestibular testing in patients who meet diagnostic criteria for BPPV without additional vestibular signs or symptoms. 1

• Imaging and specialized vestibular testing do not improve diagnostic accuracy when clinical criteria are met 1
• These tests increase costs and delay treatment without benefit 1

Special Considerations and Modifications

Assess for contraindications to standard positioning maneuvers: 1

• Cervical stenosis, severe kyphoscoliosis, limited cervical range of motion 1
• Down syndrome, severe rheumatoid arthritis, cervical radiculopathies 1
• Paget's disease, ankylosing spondylitis, morbid obesity 1

Consider alternative diagnoses if:

• Additional neurologic symptoms are present 2
• Nystagmus does not fatigue and cannot be suppressed by gaze fixation 2
• Up to one-third of cases with atypical histories may still show positive testing, so perform the maneuver even if history is not classic 2

Common Pitfalls to Avoid

Do not skip testing the opposite ear - if the first Dix-Hallpike is negative, always test the other side 1

Do not assume elderly patients will describe classic vertigo - older patients may only report instability or lightheadedness rather than spinning sensations 1, 3

Do not order imaging or vestibular testing reflexively - the diagnosis is clinical and these tests are unnecessary in straightforward cases 1, 4