What is the Dix‑Hallpike maneuver?

What is the Dix-Hallpike Maneuver?

The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior canal benign paroxysmal positional vertigo (BPPV), involving a rapid movement from sitting to supine position with the head turned 45° to one side and extended 20° below horizontal to provoke characteristic vertigo and nystagmus. 1

How to Perform the Maneuver

Patient Preparation:

• Warn the patient explicitly that the test will provoke sudden intense vertigo and possibly nausea, but symptoms will resolve within 60 seconds 2, 3
• Position the patient seated on the examination table so their head can hang off the posterior edge by approximately 20° when supine 1, 2
• Ensure you can safely support the patient's head throughout without losing balance 3

Step-by-Step Technique:

• Stand at the patient's side (e.g., right side to test right ear) 1
• Turn the patient's head 45° to the right to align the right posterior semicircular canal with the sagittal plane 1
• Rapidly move the patient from sitting to supine with head extended 20° below horizontal, maintaining the 45° rotation 1
• Keep the patient's eyes open and observe for nystagmus and vertigo 1
• Always test both sides to determine which ear is affected or if bilateral involvement exists 1, 3

What Constitutes a Positive Test

Diagnostic Criteria for Posterior Canal BPPV:

• Latency period: 5-20 seconds (rarely up to 1 minute) between completing the maneuver and onset of symptoms 1, 3
• Characteristic nystagmus: Torsional (rotatory) and upbeating (toward the forehead) pattern 1, 3
• Time-limited: Both vertigo and nystagmus increase then resolve within 60 seconds from onset 1, 3
• Crescendo-decrescendo pattern: Symptoms begin gently, increase in intensity, then decline 3

Diagnostic Accuracy and Limitations

Performance Characteristics:

• Sensitivity: 82% and specificity: 71% among specialty clinicians 1, 2
• Positive predictive value: 83% in primary care settings 1, 2
• Critical limitation: Negative predictive value only 52%, meaning a negative test does NOT rule out BPPV 1, 2

Common Pitfall: Because of the low negative predictive value, repeat the Dix-Hallpike maneuver at a separate visit if clinical suspicion remains high despite initial negative testing 1. Additionally, if the first test is negative, perform the supine roll test to evaluate for lateral canal BPPV (10-15% of cases) 1, 2.

Factors Affecting Accuracy:

• Speed of head movements during the test 1, 3
• Time of day when testing is performed 1, 3
• Angle of the occipital plane during the maneuver 1, 3

Important Safety Considerations

Exercise extreme caution or avoid the 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 to support head)

For high-risk patients: Consider referral to specialists with specialized equipment such as tilting examination tables 2, 3

When to Consider Alternative Diagnoses

If the Dix-Hallpike produces horizontal or no nystagmus in a patient with BPPV-compatible symptoms, perform a supine roll test to assess for lateral semicircular canal BPPV 1, 2.

Red flags requiring neuroimaging (MRI brain): 4

• Atypical nystagmus patterns (horizontal nystagmus or spontaneous nystagmus)
• Severe unilateral pain (not a feature of BPPV)
• Additional concerning neurologic symptoms

Special Circumstances

Bilateral BPPV: In a small percentage of cases (approximately 11%), the test may be positive bilaterally, particularly after head trauma 1, 5. Test both sides systematically to determine involvement 1, 3.

Fatigue phenomenon: With repeated testing, nystagmus and vertigo typically become weaker (BPPV fatigue), but this effect disappears within 30 minutes 6. If initial testing of posterior canals is negative, test horizontal canals, then repeat posterior canal testing as holding the head in various positions allows canaliths to collect, potentially converting a false-negative to positive 7.