How to Perform the Dix-Hallpike Maneuver
The Dix-Hallpike maneuver is performed by rotating the patient's head 45 degrees toward the side being tested while seated, then rapidly moving them to a supine position with the head hanging 20 degrees below horizontal off the examination table edge, maintaining this position while observing for characteristic nystagmus and vertigo. 1
Pre-Maneuver Preparation
Patient counseling is essential before beginning. Warn the patient that the maneuver may provoke sudden, intense rotational vertigo and possibly nausea, but reassure them these symptoms will subside within 60 seconds. 1, 2
Position the patient on the examination table so that when supine, their head can hang with support off the posterior edge by approximately 20 degrees. 1, 2 Ensure you can safely support the patient's head throughout the entire maneuver without losing your own balance or support. 1
Step-by-Step Technique
Testing the Right Ear
Begin with the patient seated upright on the examination table with you standing at their right side. 1
Rotate the patient's head 45 degrees to the right to align the right posterior semicircular canal with the sagittal plane of the body. 1
Rapidly move the patient from sitting to supine while maintaining the 45-degree head rotation, allowing the head to hang approximately 20 degrees below horizontal off the table edge. 1, 2
Maintain this position and observe the patient's eyes for nystagmus. The latency period typically ranges from 5 to 20 seconds, though it may be as long as 1 minute in rare cases. 1
Keep the patient in this position for at least 60 seconds or until the nystagmus and vertigo resolve. 1
Testing the Left Ear
The maneuver must be performed bilaterally to determine which ear is involved or if both ears are affected. 1 Repeat the exact same sequence with the head rotated 45 degrees to the left. 2
Interpreting Results
A positive test shows torsional (rotatory), upbeating nystagmus accompanied by subjective vertigo that increases then resolves within 60 seconds from onset. 2 This confirms posterior canal BPPV. 2
If the initial bilateral testing is negative but clinical suspicion remains high, repeat the Dix-Hallpike test after holding the patient in lateral positions, as this allows canaliths to collect and may convert a false-negative test to positive. 3 The test has a negative predictive value of only 52% in primary care settings. 2, 4
If horizontal or no nystagmus occurs despite BPPV-compatible symptoms, perform a supine roll test to assess for lateral semicircular canal BPPV, which accounts for 10-15% of BPPV cases. 2, 4
Critical Factors Affecting Accuracy
Speed of head movements, time of day, and the angle of the occipital plane all influence diagnostic accuracy. 1, 2 The maneuver has 82% sensitivity and 71% specificity among specialty clinicians. 2
Contraindications and Precautions
Exercise extreme caution or avoid the maneuver in patients with significant vascular disease, cervical stenosis or limited cervical range of motion, severe kyphoscoliosis, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, ankylosing spondylitis, spinal cord injuries, or morbid obesity. 2, 5 These conditions may compromise safety or accuracy. 2
For patients with physical limitations, special tilting examination tables may allow safe performance. 2 Alternatively, a side-lying maneuver with the nose turned 45 degrees away from the tested side can serve as a valid alternative when range-of-motion limitations preclude the standard Dix-Hallpike. 6
Common Pitfalls
Never assume BPPV is ruled out with a single negative test. 2, 4 The test may need repeating at a separate visit due to its limited negative predictive value. 2, 4
Always test both ears sequentially even if the first side is positive, as bilateral posterior canal BPPV can occur, particularly after head trauma. 1, 2
Do not skip testing the horizontal canals if the Dix-Hallpike is initially negative, as failure to do so may result in missed lateral canal BPPV. 2, 3