How is the Dix-Hallpike (Benign Paroxysmal Positional Vertigo) maneuver performed?

How to Perform the Dix-Hallpike Maneuver

The Dix-Hallpike maneuver is performed by rapidly moving the patient from an upright seated position with the head turned 45° toward the test ear to a supine position with the head extended 20° below horizontal, maintaining this position for 20-30 seconds to elicit characteristic nystagmus of posterior canal BPPV. 1

Pre-Maneuver Preparation

• Counsel the patient before starting that the maneuver will provoke sudden intense vertigo and possibly nausea, which will subside within 60 seconds 1, 2
• Position the patient on the examination table so that when supine, the 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

Step 1: Initial Positioning

• Begin with the patient sitting upright on the examination table 1
• Stand at the patient's side (typically the side being tested) 1
• Rotate the patient's head 45° toward the ear being tested to align the posterior semicircular canal with the sagittal plane of the body 1, 2

Step 2: Rapid Movement to Supine

• Rapidly lay the patient back to the supine head-hanging position with the head extended approximately 20° below horizontal 1
• Maintain this position for 20-30 seconds while observing for nystagmus and asking about vertigo 1

Step 3: Return to Upright

• Bring the patient back to the upright sitting position 1

Step 4: Repeat for Opposite Side

• The maneuver must be performed bilaterally to determine which ear is involved or if both ears are affected 1, 2
• Repeat the entire sequence with the head turned 45° toward the opposite ear 1

Interpreting Results

• Positive test: Torsional (rotatory) upbeating nystagmus with a brief latency period that increases then resolves within 60 seconds, accompanied by vertigo 2, 3
• The affected ear is the one positioned downward when characteristic nystagmus appears 3
• Sensitivity is 82% and specificity is 71% among specialty clinicians 2, 3

Critical Considerations for Diagnostic Accuracy

• If initial testing is negative, repeat the Dix-Hallpike test after testing horizontal canals, as holding the patient in various positions allows canaliths to collect, potentially converting a false-negative to positive 4
• Factors affecting accuracy include speed of head movements, time of day, and angle of the occipital plane 1, 2
• Repeating the maneuver sequentially can increase diagnostic yield by identifying an additional 13.5% of BPPV cases that were initially negative 5

Safety Precautions and Contraindications

Exercise extreme caution or avoid the maneuver in patients with: 1, 2

• Significant vascular disease (risk of vertebrobasilar insufficiency or stroke)
• Cervical stenosis or severe limitation of cervical range of motion
• Severe kyphoscoliosis
• Down syndrome
• Severe rheumatoid arthritis
• Cervical radiculopathies
• Paget's disease
• Ankylosing spondylitis
• Spinal cord injuries
• Morbid obesity (may require additional assistance or special tilting examination tables)

Common Pitfalls to Avoid

• Failing to test both sides: Unilateral testing misses bilateral BPPV (occurs in 11.2% of cases) and may misidentify the affected ear 6
• Not repeating the test when initially negative: A single negative test has a negative predictive value of only 52% in primary care settings 2, 3
• Inadequate head extension: The head must reach at least 20° below horizontal to properly stimulate the posterior canal 1
• Insufficient observation time: Must maintain the position for the full 20-30 seconds to allow nystagmus to develop and resolve 1