Dix-Hallpike Maneuver is the Primary Diagnostic Exam for BPPV
The Dix-Hallpike maneuver is the gold standard diagnostic test for evaluating possible benign paroxysmal positional vertigo (BPPV), specifically for posterior semicircular canal involvement, which accounts for the majority of BPPV cases. 1
Diagnostic Procedure
The Dix-Hallpike maneuver involves rapidly moving the patient from a seated position to supine with the head extended approximately 20 degrees below horizontal and rotated 45 degrees to the side being tested. 1, 2 The examiner must:
- Warn the patient explicitly that the maneuver will provoke sudden intense vertigo and possibly nausea, but symptoms will resolve within 60 seconds 2
- Position the patient so their head can hang off the examination table edge by about 20 degrees when supine 2, 3
- Turn the patient's head 45 degrees to align the posterior semicircular canal with the sagittal plane 2
- Quickly move the patient to the supine position while maintaining head rotation 2
- Test both sides to determine which ear is affected or if bilateral involvement exists 2, 3
Positive Test Criteria
A positive Dix-Hallpike indicates posterior canal BPPV when all of the following are present: 1, 2
- Latency period of 5-20 seconds between completing the maneuver and onset of symptoms 2
- Torsional (rotatory) upbeating nystagmus with a crescendo-decrescendo pattern 1, 2
- Subjective vertigo accompanying the nystagmus 3
- Both vertigo and nystagmus resolve within 60 seconds from onset 1, 2
Diagnostic Accuracy
The Dix-Hallpike maneuver has moderate sensitivity (82%) and specificity (71%) among specialty clinicians, with a positive predictive value of 83%. 1, 2 However, the negative predictive value is only 52% in primary care settings, meaning a single negative test does not rule out BPPV. 1, 2 If clinical suspicion remains high after a negative initial test, repeat the maneuver at a separate visit or consider that the test may need to be performed multiple times. 4, 5
When to Perform Additional Testing
If the Dix-Hallpike test is negative but the patient's history is compatible with BPPV, perform a supine roll test to assess for lateral semicircular canal BPPV, which accounts for 10-15% of BPPV cases. 1, 2 The supine roll test involves turning the patient's head rapidly from side to side while they lie supine, looking for horizontal nystagmus. 1
Important Contraindications and Precautions
Exercise extreme caution or avoid the Dix-Hallpike maneuver in patients with: 1, 2, 3
- Significant vascular disease (risk of stroke or vascular injury)
- Cervical stenosis or severe limitation of cervical range of motion
- Severe kyphoscoliosis
- Down syndrome
- Severe rheumatoid arthritis or ankylosing spondylitis
- Cervical radiculopathies or Paget's disease
- Spinal cord injuries
- Morbid obesity (may require additional assistance or specialized tilting examination tables)
For high-risk patients, consider referral to specialists with specialized equipment such as tilting examination tables. 2
Common Pitfalls to Avoid
Do not order routine vestibular testing or neuroimaging in patients who meet diagnostic criteria for BPPV based on a positive Dix-Hallpike test, unless the diagnosis is uncertain or there are additional neurologic symptoms unrelated to BPPV. 1, 2 The diagnosis is clinical, based on history and positive Dix-Hallpike findings. 2
Do not repeat the Dix-Hallpike maneuver multiple times in succession to demonstrate nystagmus fatigability, as this unnecessarily subjects patients to repeated vertigo symptoms and may interfere with immediate bedside treatment. 1 Fatigability is not required as a diagnostic criterion. 1
Factors that may affect diagnostic accuracy include the speed of head movements during the test, time of day when testing is performed, and the angle of the occipital plane during the maneuver. 1, 3