Dix-Hallpike Maneuver: Diagnostic Test for Posterior Canal BPPV
The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior semicircular canal benign paroxysmal positional vertigo (BPPV), used to provoke characteristic torsional upbeating nystagmus and vertigo that confirms the diagnosis. 1, 2
Primary Diagnostic Purpose
The Dix-Hallpike test diagnoses posterior canal BPPV by eliciting characteristic nystagmus when moving a patient from upright to supine position with the head turned 45° to one side and neck extended 20° with the suspected ear down 1, 2
A positive test demonstrates vertigo associated with torsional (rotatory), upbeating nystagmus toward the forehead, with a latency period between completing the maneuver and symptom onset 1, 2
The provoked symptoms increase and resolve within 60 seconds from onset, which distinguishes BPPV from central causes of vertigo 2
Diagnostic Performance
The maneuver has 82% sensitivity and 71% specificity for posterior canal BPPV among specialty clinicians, with an 83% positive predictive value 2
The test must be performed bilaterally—if the first side is negative, repeat with the other ear down before concluding a negative result 1
Critical Testing Technique
Position the patient so their head can hang approximately 20 degrees below horizontal off the examination table edge when supine, ensuring you can safely support the head throughout 2
Warn patients beforehand that the maneuver may provoke sudden intense vertigo and nausea that typically subsides within 60 seconds 2
If the initial bilateral testing is negative but clinical suspicion remains high, repeat the Dix-Hallpike maneuver—holding patients in head-hanging positions often allows canaliths to collect, converting a false-negative to positive 3, 4
When to Consider Alternative Testing
If the Dix-Hallpike exhibits horizontal or no nystagmus in a patient with positional vertigo symptoms, perform a supine roll test to assess for lateral semicircular canal BPPV, which accounts for 10-15% of BPPV cases 2
Repeating diagnostic maneuvers sequentially one more time during the initial evaluation increases diagnostic success—one study diagnosed 28 additional BPPV patients (out of 207 total) by simply repeating the maneuver 4
Contraindications and Precautions
Exercise extreme caution or avoid the maneuver in patients with: cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, ankylosing spondylitis, spinal cord injuries, known cerebrovascular disease, or morbid obesity 1, 2
For patients with physical limitations, special tilting examination tables may allow safe performance 2
Common Pitfalls
A history of positional vertigo alone is inadequate to diagnose posterior canal BPPV—you must provoke the characteristic nystagmus with the Dix-Hallpike maneuver 1
The negative predictive value is only 52% in primary care settings, meaning a negative test does not rule out BPPV; consider repeating at a separate visit if clinical suspicion persists 2
Factors affecting diagnostic accuracy include speed of head movements, time of day, and angle of the occipital plane 2
In some cases, particularly after head trauma, the test may be positive bilaterally 2