What the Dix-Hallpike Test Checks For
The Dix-Hallpike test is the gold standard diagnostic maneuver for posterior semicircular canal benign paroxysmal positional vertigo (BPPV), which is the most common form of BPPV and the most common cause of peripheral vertigo. 1
Primary Diagnostic Purpose
The Dix-Hallpike maneuver specifically diagnoses posterior canal BPPV by provoking characteristic nystagmus and vertigo when the patient is moved from sitting to a supine position with the head turned 45° to one side and extended 20° below horizontal. 1
What Constitutes a Positive Test
A positive Dix-Hallpike test confirms posterior canal BPPV when all of the following criteria are present: 1
Characteristic nystagmus pattern: Torsional (rotatory) and upbeating (toward the forehead) nystagmus that appears as a mixed movement in the midorbit 1, 2
Latency period: A delay of 5-20 seconds (rarely up to 1 minute) between completing the maneuver and onset of both vertigo and nystagmus 1, 2
Time-limited symptoms: Both the provoked vertigo and nystagmus increase in intensity (crescendo-decrescendo pattern) and then resolve within 60 seconds from onset 1, 2
Subjective rotational vertigo: The patient experiences spinning or rotational vertigo during the test 1
Diagnostic Accuracy
The test has moderate sensitivity (82%) and specificity (71%) among specialty clinicians, with a positive predictive value of 83%. 2 However, the negative predictive value is only 52% in primary care settings, meaning a single negative test does not rule out BPPV. 2
Critical Testing Considerations
Both sides must be tested to determine which ear is affected or if bilateral involvement exists, as bilateral posterior canal BPPV can occur, particularly after head trauma. 1, 2 If the first side tested is negative, the maneuver should be performed with the other ear down before concluding the test is negative. 1
Repeating the test can improve diagnostic yield: If initial testing of both posterior canals is negative but clinical suspicion remains high, holding the patient in the head-hanging and lateral positions may allow canaliths to collect, making a repeated Dix-Hallpike test positive. 3, 4 One study found that performing the maneuver sequentially one more time diagnosed an additional 28 patients out of 207 who were initially negative. 4
When to Consider Alternative Diagnoses
If the Dix-Hallpike test produces horizontal nystagmus or spontaneous nystagmus without the characteristic torsional upbeating pattern, perform a supine roll test to evaluate for lateral semicircular canal BPPV, which accounts for 10-15% of BPPV cases. 2, 5 If atypical nystagmus patterns persist, neuroimaging (MRI) should be considered to rule out central causes. 2
Important Contraindications
Exercise extreme caution or avoid the test in patients with: 1, 2
- Significant vascular disease or known cerebrovascular disease
- Cervical stenosis or severe limitation of cervical range of motion
- Severe kyphoscoliosis
- Down syndrome
- Severe rheumatoid arthritis or ankylosing spondylitis
- Cervical radiculopathies
- Spinal cord injuries
- Morbid obesity
For high-risk patients, consider referral to specialists with specialized tilting examination tables. 2