Dix-Hallpike Maneuver for BPPV Diagnosis
The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior canal BPPV in older adults with vertigo, and should be performed bilaterally at the initial visit. 1
How to Perform the Dix-Hallpike Maneuver
The test requires moving the patient through specific head positions to provoke characteristic nystagmus:
- Starting position: Patient sits upright on examination table with head rotated 45° toward the side being tested 1
- Rapid movement: Quickly lay the patient back to supine position with head hanging 20° below horizontal, maintaining the 45° rotation 1
- Observation period: Hold this position for 20-60 seconds while watching for torsional upbeating nystagmus and asking about vertigo 1
- Latency: Expect 5-20 seconds (up to 1 minute) before nystagmus appears 1
- Duration: Nystagmus and vertigo should resolve within 60 seconds of onset 1
- Bilateral testing required: Repeat the entire maneuver on the opposite side to determine which ear is affected 1
Diagnostic Accuracy and Interpretation
The Dix-Hallpike has a sensitivity of 82% and specificity of 71% among specialty clinicians, with positive predictive value of 83% but negative predictive value of only 52% in primary care settings 1. A negative test does not rule out BPPV—the maneuver should be repeated at the same visit or a subsequent visit to avoid false negatives. 1, 2
Critical Next Steps After Negative Dix-Hallpike
If the Dix-Hallpike is negative but clinical suspicion remains high:
- Perform the supine roll test immediately to assess for lateral (horizontal) canal BPPV, which accounts for 10-15% of cases 1, 3
- Repeat the Dix-Hallpike test after performing the supine roll test, as holding the patient in various positions allows canaliths to collect and may convert a false-negative to positive 2, 4
- Repeating diagnostic maneuvers at the same visit increases diagnostic yield by 20% (detecting 28 additional cases among 207 patients) 4
When to Avoid or Modify the Maneuver
Exercise caution or use alternative testing in patients with:
- Significant vascular disease (theoretical stroke risk, though no documented cases) 1
- Severe cervical stenosis, kyphoscoliosis, or limited cervical range of motion 1
- Severe rheumatoid arthritis, cervical radiculopathies, or ankylosing spondylitis 1
- Morbid obesity (may require additional assistance or specialized tilting tables) 1
- Down syndrome, Paget's disease, or spinal cord injuries 1
For these patients, consider an abbreviated diagnostic maneuver using only a backed chair (sensitivity 80%, specificity 95%) or refer to specialized vestibular testing 5.
Common Diagnostic Pitfalls
Do not repeat the Dix-Hallpike multiple times to demonstrate fatigability—this unnecessarily subjects patients to repeated vertigo and may interfere with immediate treatment 1. The presence of nystagmus and vertigo on first testing is sufficient for diagnosis.
Do not order imaging or vestibular testing in patients who meet diagnostic criteria for BPPV unless there are atypical neurological signs or symptoms unrelated to BPPV 1, 3.