In-Office Testing for Vertigo
The Dix-Hallpike maneuver performed bilaterally is the gold standard in-office test for diagnosing posterior canal BPPV (the most common cause of vertigo), and if negative or showing horizontal nystagmus, it must be followed by the supine roll test to diagnose lateral canal BPPV. 1
Primary Diagnostic Approach: The Dix-Hallpike Maneuver
Perform the Dix-Hallpike maneuver bilaterally on every patient presenting with positional vertigo symptoms. 2 This test diagnoses posterior canal BPPV, which accounts for 85-95% of all BPPV cases. 1
Technique:
- Position the patient upright with head turned 45° toward the test ear 1
- Rapidly move the patient to supine position with head extended 20° beyond horizontal (head-hanging position) 1
- Maintain this position for 20-30 seconds while observing for nystagmus 1
- Repeat on the opposite side 1
Positive Test Findings:
- Torsional and upbeating nystagmus (most characteristic) 2
- Latency period of 5-20 seconds before nystagmus onset 2
- Symptoms and nystagmus that crescendo then resolve within 60 seconds 2
- Subjective vertigo accompanying the nystagmus 2
Diagnostic Performance:
The Dix-Hallpike has a sensitivity of 79-82% and specificity of 71-75% for posterior canal BPPV. 1, 3 A negative test does not rule out BPPV - the negative predictive value is only 52% in primary care settings, so repeat testing at a separate visit may be necessary if clinical suspicion remains high. 1
Secondary Test: The Supine Roll Test
If the Dix-Hallpike is negative or shows horizontal (rather than torsional upbeating) nystagmus, immediately perform the supine roll test. 1, 2 This is critical because lateral canal BPPV accounts for 10-15% of BPPV cases and is commonly missed. 1, 4
Technique:
- Position patient supine with head in neutral position 1, 4
- Quickly rotate head 90° to one side while observing for nystagmus 1, 4
- After nystagmus subsides, return head to center 1
- Then quickly rotate head 90° to the opposite side 1, 4
Positive Test Findings:
- Horizontal nystagmus beating toward the undermost ear (geotropic type) - most common pattern 1, 4
- The side with the strongest nystagmus is typically the affected ear 4
- Warn patients this test may provoke intense temporary dizziness 1, 4
Critical Red Flags Requiring Urgent Evaluation
During nystagmus assessment, immediately recognize these central warning signs that indicate stroke or other serious pathology rather than benign BPPV: 2
- Downbeating nystagmus
- Direction-changing nystagmus without head position changes
- Gaze-holding nystagmus
- Baseline nystagmus present without any provocative maneuvers
Note that one-third to two-thirds of stroke patients presenting with vertigo lack focal neurologic deficits, so absence of focal findings does not rule out stroke. 2
Important Contraindications and Modifications
Avoid or modify the Dix-Hallpike maneuver in patients with: 1, 2
- Significant vascular disease (stroke risk)
- Severe cervical stenosis
- Severe kyphoscoliosis or limited cervical range of motion
- Down syndrome
- Severe rheumatoid arthritis or cervical radiculopathies
- Morbid obesity (may require additional assistance or specialized tilting tables)
For these patients, refer to specialized clinicians with appropriate equipment and resources. 1
Common Pitfalls to Avoid
- Do not rely solely on patient's description of "dizziness" without performing objective positional testing 2
- Do not skip the supine roll test when Dix-Hallpike is negative - lateral canal BPPV is frequently missed 2, 4
- Do not assume a single negative Dix-Hallpike rules out BPPV - repeat testing may be needed 1
- Do not perform only unilateral testing - bilateral testing is essential to identify the affected side and detect bilateral BPPV 1, 2
The Dix-Hallpike test is both underutilized (only 53% of appropriate patients receive it) and misapplied (29% performed on patients with symptoms inconsistent with BPPV), which can lead to missed diagnoses of central causes. 5