What is the Dix-Hallpike test for diagnosing benign paroxysmal positional vertigo (BPPV)?

Dix-Hallpike Test for Vertigo

What It Is

The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior canal benign paroxysmal positional vertigo (BPPV), involving rapid repositioning of the patient from sitting to supine with head extended 20 degrees below horizontal and rotated 45 degrees to test each ear separately. 1, 2

Step-by-Step Procedure

Pre-Test Preparation

• Warn the patient explicitly that the maneuver will provoke sudden intense vertigo and possibly nausea, but symptoms will resolve within 60 seconds 2, 3
• Position the patient seated so their head can hang off the posterior edge of the examination table by approximately 20 degrees when supine 2, 3
• Ensure you can safely support the patient's head throughout the entire maneuver without losing balance 3

Performing the Test

• Start with the patient sitting upright on the examination table 3
• Turn the patient's head 45 degrees toward the side being tested (e.g., right side first) to align the posterior semicircular canal with the sagittal plane 2, 3
• Rapidly move the patient from sitting to supine with the head extended 20 degrees below horizontal, maintaining the 45-degree head rotation 2, 3
• Observe for nystagmus and ask about vertigo symptoms 1, 2
• Wait up to 60 seconds for symptoms to appear and resolve 2, 3
• Return patient slowly to upright position after symptoms resolve 1
• Repeat the entire sequence for the opposite side 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 of 5-20 seconds between completing head positioning and onset of symptoms 3
• Torsional (rotatory) upbeating nystagmus with a crescendo-decrescendo pattern 1, 3
• Subjective vertigo accompanying the nystagmus 1, 2
• Both vertigo and nystagmus resolve within 60 seconds from onset 2, 3
• Reversal of nystagmus direction may occur when returning to upright position 1, 3

Diagnostic Accuracy

• Sensitivity of 82% and specificity of 71% among specialty clinicians 1, 2
• Positive predictive value of 83% but negative predictive value of only 52% in primary care settings 1, 2
• A negative test does NOT rule out BPPV - the test may need repeating at a separate visit 1, 2
• Factors affecting accuracy include speed of head movements, time of day, and angle of the occipital plane 1, 3

Critical Pitfalls to Avoid

Don't Stop After One Negative Test

• If the first Dix-Hallpike is negative, perform a supine roll test to assess for lateral semicircular canal BPPV (10-15% of BPPV cases) 2, 3
• Consider repeating the Dix-Hallpike at a separate visit if clinical suspicion remains high 1, 2
• Some patients require being held in head-hanging positions to allow canaliths to collect before the test becomes positive 4

Don't Forget to Test Both Sides

• Always test both ears bilaterally to determine which ear is affected 1, 3
• Bilateral posterior canal BPPV occurs in a small percentage of cases, especially after head trauma 1, 3

Don't Repeat to Demonstrate Fatigability

• Although nystagmus typically fatigues with repeated maneuvers, do not repeat the test solely to demonstrate this as it unnecessarily subjects patients to repeated vertigo and may interfere with immediate treatment 1

Safety Contraindications

Exercise extreme caution or avoid the test entirely in patients with: 1, 2, 3

• Significant vascular disease (theoretical stroke risk, though no documented cases exist) 1, 3
• Cervical stenosis or severe limitation of cervical range of motion 1, 2
• Severe kyphoscoliosis 1, 2
• Down syndrome 1, 2
• Severe rheumatoid arthritis or ankylosing spondylitis 1, 3
• Cervical radiculopathies 1, 3
• Paget's disease 1, 3
• Spinal cord injuries 1, 2
• Morbid obesity 1, 2

For high-risk patients, consider referral to specialists with specialized tilting examination tables 3

When to Consider Alternative Diagnoses

• If the test produces horizontal nystagmus or spontaneous nystagmus without the characteristic pattern, consider MRI of the brain as acute brain lesions were detected in 11% of such patients 3
• If nystagmus findings are atypical or equivocal, consider comprehensive vestibular testing 3
• Do not order routine vestibular testing or neuroimaging in patients who meet diagnostic criteria for BPPV without additional concerning neurologic symptoms 3