How to Perform the Dix-Hallpike Exam
The Dix-Hallpike maneuver involves rapidly moving the patient from sitting upright to supine with the head turned 45° to one side and extended 20° below horizontal, holding this position while observing for characteristic torsional upbeating nystagmus and vertigo that appears after 5-20 seconds and resolves within 60 seconds. 1, 2
Pre-Test Preparation
Explicitly warn the patient that the maneuver will provoke sudden intense vertigo and possibly nausea, but reassure them these symptoms will resolve within 60 seconds. 2
Position the patient seated on the examination table so that when supine, their head can hang off the posterior edge by approximately 20 degrees. 2, 3
Ensure you can safely support the patient's head throughout the entire maneuver without losing your own balance. 2
Step-by-Step Procedure
Testing the Right Ear
Stand at the patient's right side while they sit upright on the examination table. 2
Turn the patient's head 45 degrees to the right to align the right posterior semicircular canal with the sagittal plane of the body. 2
Quickly move the patient from sitting to supine with the head extended 20 degrees below horizontal, maintaining the 45-degree head rotation throughout. 1, 2
Hold this position for at least 20-40 seconds while carefully observing the patient's eyes for nystagmus and asking about vertigo symptoms. 2
Testing the Left Ear
Return the patient to sitting position and allow symptoms to resolve before proceeding. 2
Repeat the entire maneuver on the opposite side by turning the head 45 degrees to the left and bringing the patient to supine with left ear down. 1, 2
Always test both sides to determine which ear is affected or if bilateral involvement exists, as bilateral posterior canal BPPV can occur, particularly after head trauma. 2, 3
Interpreting a Positive Test
A positive test demonstrates four key features: 2
- Latency period of 5-20 seconds between completing the head positioning and onset of symptoms (rarely up to 60 seconds). 2
- Torsional (rotatory) upbeating nystagmus that appears as a mixed movement with a crescendo-decrescendo pattern. 2
- Subjective rotational vertigo accompanying the nystagmus. 2
- Resolution within 60 seconds from the onset of nystagmus, with both vertigo and nystagmus increasing then declining. 2
When returning the patient to upright after a positive test, you may observe reversal of the nystagmus direction. 2
The nystagmus typically fatigues (reduced response) with repeated maneuvers, a phenomenon that usually disappears within 30 minutes. 2, 4
Critical Diagnostic Considerations
If the initial Dix-Hallpike is negative but clinical suspicion remains high, perform a supine roll test to evaluate for lateral semicircular canal BPPV, which accounts for 10-15% of BPPV cases. 1, 2
A single negative test does not rule out BPPV, as the negative predictive value is only 52% in primary care settings. 2, 3
If the test exhibits horizontal nystagmus or spontaneous nystagmus without the characteristic torsional upbeating pattern, this suggests a different diagnosis and warrants neuroimaging. 2
Consider repeating the posterior canal testing after performing the supine roll test, as holding the patient in various positions may allow canaliths to collect, making a previously negative Dix-Hallpike become positive. 5
Safety Contraindications
Exercise extreme caution or avoid the test entirely in patients with: 2, 3
- Significant vascular disease or vertebrobasilar insufficiency risk
- Cervical stenosis or severe limitation of cervical range of motion
- Severe kyphoscoliosis
- Down syndrome
- Severe rheumatoid arthritis or ankylosing spondylitis
- Cervical radiculopathies
- Paget's disease
- Spinal cord injuries
- Morbid obesity
For high-risk patients, consider referral to specialists with specialized tilting examination tables to minimize risks. 2
Common Pitfalls to Avoid
Do not perform the test too slowly, as the speed of head movements affects diagnostic accuracy. 2, 3
Do not test only one side, as this may miss unilateral or bilateral involvement. 1, 2
Do not hold the position for less than 20 seconds, as the latency period may extend up to 60 seconds in rare cases. 2
Do not order routine vestibular testing or neuroimaging in patients who meet diagnostic criteria for BPPV without additional concerning neurologic symptoms, as the diagnosis is clinical. 2