What are the steps to perform the Dix-Hallpike test on a patient?

How to Perform the Dix-Hallpike Test

The Dix-Hallpike maneuver involves rapidly moving the patient from sitting upright to supine with the head extended 20 degrees below horizontal and rotated 45 degrees toward the tested ear, holding this position for at least 60 seconds while observing for characteristic torsional upbeating nystagmus and vertigo. 1, 2

Pre-Test Patient Preparation

• Counsel the patient before beginning that the maneuver will provoke sudden intense vertigo and possibly nausea, but symptoms will typically subside within 60 seconds 2
• Position the examination table so the patient's head can "hang" off the posterior edge by approximately 20 degrees when supine, ensuring you can safely support the patient's head throughout the entire maneuver 2

Step-by-Step Procedure

Initial Positioning

• Seat the patient upright on the examination table with legs extended, positioned far enough back that when lying down, the head will extend beyond the table edge 2
• Turn the patient's head 45 degrees toward the ear being tested while the patient remains sitting 1, 2

The Maneuver Itself

• Rapidly move the patient from sitting to supine while maintaining the 45-degree head rotation, allowing the head to extend approximately 20 degrees below horizontal off the table edge 2, 3
• Support the patient's head throughout the maneuver to prevent injury 2
• Hold this position for at least 60 seconds while carefully observing the patient's eyes for nystagmus 1, 2

Observation Period

• Watch for a latency period of 5-20 seconds (rarely up to 1 minute) between completing the positioning and onset of symptoms 1
• Look specifically for torsional (rotatory) upbeating nystagmus with a crescendo-decrescendo pattern that begins gently, increases in intensity, then declines 1
• Both vertigo and nystagmus should increase then resolve within 60 seconds from onset 1, 2

Returning to Upright

• Slowly return the patient to the sitting position 1
• Observe for reversal of nystagmus direction, which may occur with a positive test 1

Bilateral Testing Required

• Always test both sides to determine which ear is affected or if bilateral involvement exists 1, 2
• Perform the identical maneuver on the opposite side, rotating the head 45 degrees toward the other ear 2
• Bilateral posterior canal BPPV occurs in a small percentage of cases, particularly after head trauma 1

If Initial Testing is Negative

• If the first Dix-Hallpike test on both sides is negative but clinical suspicion remains, perform a supine roll test to evaluate for lateral semicircular canal BPPV, which accounts for 10-15% of BPPV cases 1, 2
• Consider repeating the Dix-Hallpike test, as holding the patient in various positions may allow canaliths to collect, making a subsequent test positive 3
• The negative predictive value is only 52% in primary care settings, so a single negative test does not rule out BPPV 1, 2

Important Safety Considerations and Contraindications

• Exercise caution 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, 4
• Although no documented cases exist of vertebrobasilar insufficiency provoked by the Dix-Hallpike maneuver, remain vigilant in high-risk patients 1
• For patients with physical limitations, special tilting examination tables may allow safe performance 2

Common Pitfalls to Avoid

• Do not assume BPPV is ruled out with a single negative test given the 52% negative predictive value 1, 2
• Ensure adequate head extension below horizontal—insufficient extension reduces sensitivity 2
• The speed of head movements, time of day, and angle of the occipital plane all affect diagnostic accuracy 2
• Always perform bilateral testing; testing only one side misses unilateral or bilateral disease 1, 2
• If horizontal nystagmus or spontaneous nystagmus without the characteristic pattern occurs, consider MRI of the brain as this detected acute brain lesions in 11% of patients with atypical presentations 1

Interpreting Results

• Positive test: Torsional upbeating nystagmus with vertigo after 5-20 second latency, both resolving within 60 seconds, indicates posterior canal BPPV with 82% sensitivity and 71% specificity 1, 2
• The nystagmus typically fatigues (reduced response) with repeated maneuvers 1
• In up to one-third of cases with atypical histories, the test will still reveal positional nystagmus strongly suggesting posterior canal BPPV 1