Video Head Impulse Test (vHIT) in BPPV Diagnosis and Management
Direct Recommendation
vHIT should NOT be routinely ordered for diagnosing or managing BPPV when the diagnosis is clear based on history and Dix-Hallpike testing. 1, 2
When vHIT is NOT Indicated
BPPV with typical presentation does not require vHIT or any vestibular function testing when diagnostic criteria are met through clinical examination and positive Dix-Hallpike test 1, 2
The diagnosis of BPPV relies on clinical history and physical examination with positive Dix-Hallpike testing, which can be accomplished without specialized equipment 1
Ordering routine vestibular testing including vHIT for clear BPPV diagnoses leads to unnecessary costs, delays treatment, and provides no improvement in diagnostic accuracy 1, 3, 2
Research confirms that currently available vHIT equipment is not useful in diagnosing typical BPPV, as VOR gains are not significantly reduced in posterior canal BPPV and saccades are present in only a minority of cases 4
When vHIT May Be Appropriate
vHIT testing becomes appropriate only when specific red flags or atypical features are present: 1, 3, 2
Atypical clinical presentation that does not fit classic BPPV patterns 1, 3, 2
Equivocal or unusual nystagmus patterns on positional testing that are difficult to interpret 1, 2
Additional neurological symptoms suggesting accompanying CNS or otologic disorders beyond typical BPPV 1, 3, 2
Multiple concurrent peripheral vestibular disorders suspected based on clinical presentation 1, 2
Failed response to appropriate canalith repositioning procedures after adequate treatment attempts 2
Frequent recurrences of BPPV that suggest additional vestibular pathology 2
Specific Clinical Scenario Where vHIT May Help
Positional downbeat nystagmus (PDN) presents a unique situation where vHIT can help differentiate anterior canal BPPV from non-ampullary posterior canal involvement, as these are clinically difficult to distinguish 5
In PDN cases, selective VOR gain deficit on vHIT for a single vertical canal can identify which canal is involved and guide appropriate canalith repositioning procedures 5
Common Pitfalls to Avoid
Do not order vHIT reflexively for every vertigo patient—this increases costs without improving outcomes for typical BPPV 1, 3, 2
Do not delay treatment while waiting for vHIT results when clinical diagnosis is clear—immediate canalith repositioning is the appropriate management 1, 6
Do not interpret normal vHIT as ruling out BPPV—VOR gains are typically normal or only minimally reduced in BPPV, unlike vestibular neuritis where gains are significantly reduced 4, 7
Understand that vHIT primarily assesses high-frequency VOR function and is most useful for detecting vestibular nerve dysfunction (as in vestibular neuritis with 87.9% sensitivity), not BPPV 7
Algorithmic Approach
For suspected BPPV, follow this sequence: 1, 6
- Obtain focused history for brief positional vertigo episodes
- Perform Dix-Hallpike test for posterior canal involvement
- If positive: proceed immediately with Epley maneuver
- If negative but suspicion remains: perform supine roll test for horizontal canal
- Only order vHIT if: atypical features present, unusual nystagmus patterns, additional neurological symptoms, or failed treatment response 1, 3, 2
Key Evidence Distinctions
The guidelines strongly emphasize that video-oculographic technology (including vHIT) may be used to help identify and differentiate types of BPPV when available, but this is distinct from comprehensive vestibular testing 1. The technology can enlarge and replay nystagmus for detailed analysis, but routine comprehensive vestibular function testing including formal vHIT protocols is not recommended for straightforward BPPV 1, 2.