How to assess for Benign Paroxysmal Vertigo (BPV)?

How to Assess for Benign Paroxysmal Positional Vertigo (BPPV)

Diagnose BPPV through clinical history and bedside positional testing—specifically the Dix-Hallpike maneuver for posterior canal BPPV and the supine roll test for lateral canal BPPV—without obtaining imaging or vestibular testing in patients who meet diagnostic criteria. 1, 2

Clinical History Assessment

Obtain a focused history looking for these specific features:

• Brief episodes of vertigo (lasting less than 60 seconds) triggered by specific head position changes relative to gravity, such as rolling over in bed, looking up, or bending forward 3
• Rotational/spinning sensations or alternatively lightheadedness, dizziness, nausea, or feeling "off balance" 3
• Approximately 50% of patients report subjective imbalance between classic BPPV episodes 3
• Many patients modify their movements to avoid triggering vertigo 3
• BPPV does not cause: constant severe dizziness unaffected by position, hearing loss, or fainting 1

Diagnostic Testing Algorithm

Step 1: Perform the Dix-Hallpike Maneuver (Posterior Canal Testing)

Technique: Bring the patient from upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, then repeat with the opposite ear down if initial maneuver is negative 1, 2

Positive test criteria:

• Latency period of 5-20 seconds before onset of nystagmus and vertigo 4, 3
• Torsional, upbeating nystagmus toward the affected ear 1, 3
• Vertigo and nystagmus that increase then resolve within 60 seconds 4, 3
• The affected ear is the one facing downward during the positive test 4

The Dix-Hallpike maneuver has a sensitivity of 82% and specificity of 71% for posterior canal BPPV 4

Step 2: Perform the Supine Roll Test (Lateral Canal Testing)

When to perform: If the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus 1

Technique: Position the patient supine with head neutral, then quickly rotate the head 90° to one side, observe for nystagmus, return to neutral, then rotate 90° to the opposite side 4, 2, 3

Positive test criteria:

• Horizontal nystagmus during head rotation 4, 3
• Geotropic type (most common): nystagmus beats toward the undermost ear on both sides; the side with stronger nystagmus is the affected ear 4, 3
• Apogeotropic type: nystagmus beats away from the undermost ear; the side opposite the stronger nystagmus is the affected ear 4

Lateral canal BPPV accounts for 10-15% of BPPV cases and is frequently missed when clinicians skip this test 4

What NOT to Do

• Do not obtain radiographic imaging (CT or MRI) in patients who meet diagnostic criteria for BPPV in the absence of additional neurologic signs or symptoms inconsistent with BPPV 1, 2, 3
• Do not order vestibular testing (caloric testing, vHIT, VEMPs) in patients who meet diagnostic criteria for BPPV without additional vestibular signs or symptoms 1, 2, 3
• Do not skip the supine roll test in patients with negative Dix-Hallpike but classic BPPV history, as lateral canal BPPV is frequently missed 4

Special Considerations and Pitfalls

Assess for Modifying Factors Before Testing

Evaluate patients for factors that modify management 1:

• Impaired mobility or balance
• Central nervous system disorders
• Lack of home support
• Increased risk for falling (especially in elderly patients)
• Severe cervical stenosis, rheumatoid arthritis, cervical radiculopathies, or spinal issues that may require modified testing positions 2, 3

Important Clinical Nuances

• Repeated testing may be necessary to increase diagnostic yield, as BPPV fatigue phenomenon may cause diminished response that typically resolves within 30 minutes 4
• Multiple canal involvement occurs in 4.6-6.8% of cases, most commonly ipsilateral posterior and lateral canals 4
• Canal conversion may occur, with up to 6% of patients initially treated for lateral canal BPPV converting to posterior canal BPPV, and vice versa 4
• Up to one-third of cases with atypical histories of positional vertigo may still show positive Dix-Hallpike testing 3
• Presenting symptoms are often indistinguishable between posterior and lateral canal BPPV based on history alone 4

When to Consider Alternative Diagnoses

Consider other causes if the patient has 1, 3:

• Additional neurologic symptoms
• Nystagmus that does not fatigue and cannot be suppressed by gaze fixation
• Constant severe dizziness unaffected by position or movement
• Hearing loss or tinnitus (consider Ménière's disease)
• Fainting episodes

Reassessment Protocol

Reassess patients within 1 month after initial diagnosis or treatment to document resolution or persistence of symptoms 1, 2

If symptoms persist 2:

• Repeat diagnostic testing to confirm persistent BPPV
• Check for canal conversion
• Evaluate for multiple canal involvement
• Consider referral to a specialist who can evaluate for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders 1