What is the procedure for performing the Dix-Hallpike (Dix-Hallpike maneuver) test?

How to Perform the Dix-Hallpike Maneuver

The Dix-Hallpike maneuver is performed by 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, while observing for characteristic torsional upbeating nystagmus after a latency period of 5-20 seconds. 1

Pre-Procedure 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 1
• Position the patient initially sitting upright on the examination table, ensuring their head can "hang" off the posterior edge when supine, achieving approximately 20 degrees of extension below horizontal 1
• The clinician must be able to safely support the patient's head throughout the entire maneuver 1

Step-by-Step Procedure

Starting Position

• Begin with the patient sitting upright on the examination table 1
• Turn the patient's head 45 degrees toward the ear being tested 1, 2

The Maneuver

• Rapidly move the patient from sitting to supine position while maintaining the 45-degree head rotation 1, 3
• The patient's head should extend at least 10-20 degrees below the horizontal plane, hanging off the edge of the table 1, 3
• Support the patient's head throughout this movement 1

Observation Period

• Observe the patient's eyes for nystagmus for at least 20-60 seconds after completing the positioning 1, 2
• A latency period of 5-20 seconds (rarely up to 1 minute) occurs between completing the head positioning and onset of symptoms 2
• A positive test shows torsional (rotatory) upbeating nystagmus with a crescendo-decrescendo pattern, beginning gently, increasing in intensity, then declining 2
• Both vertigo and nystagmus should resolve within 60 seconds from onset 1, 2

Bilateral Testing

• The maneuver must be performed on both sides to determine which ear is affected 2
• Return the patient to upright position (reversal of nystagmus direction may be observed) 2
• Repeat the entire sequence with the head turned 45 degrees toward the opposite ear 2

Critical Technical Factors

• Speed of head movements affects diagnostic accuracy - the transition should be rapid 4
• The angle of the occipital plane during the maneuver impacts results 4
• Time of day may affect diagnostic accuracy 4

Diagnostic Interpretation

• Sensitivity is 82% and specificity is 71% among specialty clinicians, with a positive predictive value of 83% but negative predictive value of only 52% 1, 2
• A single negative test does not rule out BPPV - the maneuver may need repeating at a separate visit 4, 1
• If horizontal or no nystagmus appears despite compatible history, perform a supine roll test to assess for lateral canal BPPV 4

Important Safety Considerations and Contraindications

Exercise extreme caution or avoid the maneuver in patients with:

• Significant vascular disease (theoretical stroke risk, though no documented cases exist) 4
• Cervical stenosis or severe limitation of cervical range of motion 4
• Severe kyphoscoliosis 4
• Down syndrome 4
• Severe rheumatoid arthritis 4
• Cervical radiculopathies 4
• Paget's disease 4
• Ankylosing spondylitis 4
• Low back dysfunction or spinal cord injuries 4
• Morbid obesity (may require additional assistance or special tilting examination tables) 4

Common Pitfalls to Avoid

• Failing to test both sides - bilateral testing is mandatory to identify the affected ear(s) 2
• Not waiting long enough for nystagmus - observe for the full latency period of up to 20 seconds (rarely 60 seconds) 2
• Accepting a single negative test as definitive - repeat testing may be necessary, especially if clinical suspicion remains high 4, 1
• Inadequate head extension - the head must hang at least 10-20 degrees below horizontal 1, 3
• Not repeating the posterior canal test after horizontal canal testing - holding patients in various positions allows canaliths to collect, potentially converting a false-negative to positive 3