How do you perform the Dix-Hallpike (Benign Paroxysmal Positional Vertigo diagnostic test) maneuver on a patient?

How to Perform the Dix-Hallpike Maneuver

The Dix-Hallpike maneuver is performed by rapidly moving the patient from sitting upright with their head turned 45 degrees to one side, to supine with the head extended 20 degrees below horizontal while maintaining the head rotation, then observing for characteristic torsional upbeating nystagmus and vertigo after a 5-20 second latency period. 1

Pre-Test Patient Preparation

• Explicitly warn the patient that the maneuver will provoke sudden intense vertigo and possibly nausea, but reassure them these symptoms will resolve within 60 seconds. 1

• Position the patient seated on the examination table so that when supine, their head can hang off the posterior edge by approximately 20 degrees. 1

• Ensure you can safely support the patient's head throughout the entire maneuver without losing your own balance. 1

Step-by-Step Procedure

Starting Position:

• Begin with the patient sitting upright on the examination table with you standing at their side (typically starting on the right). 1

Head Positioning:

• Turn the patient's head 45 degrees to the right to align the right posterior semicircular canal with the sagittal plane of the body. 1

The Maneuver:

• Quickly move the patient from sitting to supine with the head extended 20 degrees below horizontal (hanging off the table edge), maintaining the 45-degree head rotation throughout. 1

• Hold this position for at least 20-60 seconds while observing the patient's eyes for nystagmus. 1

Observation Period:

• Watch for a latency period of 5-20 seconds (rarely up to 1 minute) between completing the positioning and onset of symptoms. 1

• Look for torsional (rotatory) and upbeating nystagmus with a crescendo-decrescendo pattern that resolves within 60 seconds. 1

Return to Upright:

• Slowly return the patient to sitting position, observing for reversal of nystagmus direction. 1

Repeat on Opposite Side:

• Always test both sides to determine which ear is affected or if bilateral involvement exists. 1, 2

Critical Testing Nuances

If Initial Test is Negative:

• If the first Dix-Hallpike is negative but clinical suspicion remains high, perform a supine roll test to evaluate for lateral canal BPPV (10-15% of cases). 1

• Repeat the Dix-Hallpike maneuver after testing horizontal canals, as holding the patient in various positions allows canaliths to collect, potentially converting a false negative to positive. 3, 4

• Repeating the maneuver sequentially can increase diagnostic yield by detecting an additional 20% of BPPV cases that were initially negative. 4

Factors Affecting Accuracy:

• The test's diagnostic accuracy is influenced by speed of head movements, time of day, and angle of the occipital plane during the maneuver. 1

• The sensitivity is 82% and specificity is 71% among specialists, with a positive predictive value of 83% but a concerning negative predictive value of only 52% in primary care settings. 1, 2

Absolute Contraindications and Safety Precautions

Exercise extreme caution or avoid the test entirely in patients with: 1, 2

• Significant vascular disease
• Cervical stenosis or severe limitation of cervical range of motion
• Severe kyphoscoliosis
• Down syndrome
• Severe rheumatoid arthritis or ankylosing spondylitis
• Cervical radiculopathies
• Paget's disease
• Spinal cord injuries
• Morbid obesity

For high-risk patients, consider referral to specialists with tilting examination tables to minimize risks. 1

Interpreting a Positive Test

A positive test requires ALL of the following: 1

• Latency period of 5-20 seconds after positioning
• Torsional (rotatory) and upbeating nystagmus toward the forehead
• Crescendo-decrescendo pattern of nystagmus
• Subjective rotational vertigo
• Resolution of both vertigo and nystagmus within 60 seconds from onset

The nystagmus typically fatigues (reduced response) with repeated maneuvers, which is characteristic of BPPV. 1

Red Flags Requiring Imaging

Order MRI brain if: 1, 5

• The Dix-Hallpike produces horizontal nystagmus instead of torsional upbeating
• Spontaneous nystagmus without the characteristic pattern
• Severe unilateral pain (not a feature of BPPV)
• Additional concerning neurologic symptoms

MRI detected acute brain lesions in 11% of patients with episodic vertigo and negative/atypical Dix-Hallpike testing. 1

Common Pitfalls to Avoid

• Do not perform the test only once on one side – bilateral testing is mandatory, as bilateral posterior canal BPPV occurs in a small percentage of cases, particularly after head trauma. 1

• Do not rule out BPPV with a single negative test – the negative predictive value is only 52% in primary care, and repeating the maneuver or testing at a separate visit may be necessary. 2, 4

• Do not order routine vestibular testing or neuroimaging in patients who meet diagnostic criteria for BPPV without additional concerning neurologic symptoms, as the diagnosis is clinical. 1