Dix-Hallpike Test for BPPV Diagnosis
The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior canal benign paroxysmal positional vertigo (BPPV), the most common form of BPPV. 1, 2
How to Perform the Dix-Hallpike Maneuver
Before starting, warn the patient that the test will provoke sudden, intense vertigo and possibly nausea that typically resolves within 60 seconds. 2
Positioning technique:
- Position the patient so their head can extend ("hang") approximately 20 degrees below horizontal off the examination table edge when supine 2, 3
- From sitting, rapidly move the patient to supine position with head turned 45 degrees to one side and extended 20 degrees below horizontal 1, 4
- Observe for nystagmus and ask about vertigo 1
- After symptoms resolve, slowly return patient to upright (may see reversal nystagmus) 1
- Repeat the entire maneuver on the opposite side to complete the test 1, 2
What Constitutes a Positive Test
A positive Dix-Hallpike indicates posterior canal BPPV when ALL of the following occur: 2, 3
- Latency period: 5-20 seconds (rarely up to 60 seconds) between completing head positioning and symptom onset 3
- Characteristic nystagmus: Torsional (rotatory) AND upbeating pattern with crescendo-decrescendo intensity 3
- Time-limited: Both vertigo and nystagmus resolve within 60 seconds from onset 2, 3
- Subjective vertigo: Patient reports rotational or spinning sensation 3
Diagnostic Accuracy and Limitations
The test has moderate sensitivity (82%) and specificity (71%) among specialists, with positive predictive value of 83% but concerning negative predictive value of only 52% in primary care. 1, 4
Critical pitfall: A negative test does NOT rule out BPPV. 1 Consider repeating the maneuver at a separate visit if clinical suspicion remains high, as false negatives are common. 1
Factors affecting accuracy include: 1
- Speed of head movements during the test
- Time of day when performed
- Angle of the occipital plane
When the Dix-Hallpike is Negative
If the patient has positional vertigo symptoms but negative Dix-Hallpike, perform a supine roll test to evaluate for lateral (horizontal) canal BPPV, which accounts for 10-15% of BPPV cases. 1, 2
Some patients require repeated testing after being held in various positions, as this allows canaliths to collect and may convert an initially negative test to positive. 5
Safety Considerations and Contraindications
Exercise extreme caution or avoid the test in patients with: 1, 2
- Significant vascular disease (theoretical stroke risk, though never documented)
- Cervical stenosis or severe limitation of cervical range of motion
- Severe kyphoscoliosis
- Down syndrome
- Severe rheumatoid arthritis or ankylosing spondylitis
- Cervical radiculopathies or spinal cord injuries
- Morbid obesity (may require additional personnel or specialized tilting tables)
For high-risk patients, consider referral to specialists with specialized equipment such as tilting examination tables. 1
Bilateral Testing is Mandatory
Always test both sides to determine which ear is affected, as approximately 5-10% of cases involve bilateral posterior canal BPPV, particularly after head trauma. 1, 3
When to Consider Additional Testing
Do NOT order routine vestibular testing or neuroimaging in patients who meet diagnostic criteria for BPPV without additional concerning neurologic symptoms. 1 The diagnosis is clinical, based on history and positive Dix-Hallpike findings. 1
Consider comprehensive vestibular testing only if: 1
- Nystagmus findings are atypical or equivocal
- Additional symptoms suggest concurrent CNS or otologic disorders
- Multiple peripheral vestibular disorders are suspected