Is the Dix‑Hallpike maneuver preferable to the Epley maneuver as the initial diagnostic test for benign paroxysmal positional vertigo in an adult presenting with brief positional vertigo?

Dix-Hallpike is the Diagnostic Test, Not Epley

The Dix-Hallpike maneuver is the gold standard diagnostic test for BPPV, while the Epley maneuver is a treatment intervention—these serve entirely different purposes and are not interchangeable. 1, 2

Understanding the Fundamental Difference

The question reflects a common misconception about these maneuvers:

• Dix-Hallpike is diagnostic: This maneuver provokes characteristic nystagmus and vertigo to confirm the diagnosis of posterior canal BPPV 1, 2
• Epley is therapeutic: This is a canalith repositioning maneuver used to treat BPPV after diagnosis has been established 3

The Dix-Hallpike as Gold Standard Diagnostic Test

The American Academy of Otolaryngology-Head and Neck Surgery designates the Dix-Hallpike maneuver as the gold standard for diagnosing posterior canal BPPV, which accounts for the majority of BPPV cases. 1, 2

Diagnostic Performance Characteristics

• Sensitivity: 82% and specificity: 71% among specialty clinicians 2, 4
• Positive predictive value: 83%, meaning when positive, it reliably confirms posterior canal BPPV 2, 4
• Negative predictive value: only 52% in primary care settings, indicating a single negative test does not rule out BPPV 2, 4

What Constitutes a Positive Test

A positive Dix-Hallpike requires all of the following criteria 1, 2:

• Latency period of 5-20 seconds between completing the maneuver and onset of symptoms 2
• Torsional (rotatory) and upbeating nystagmus toward the forehead 1, 2
• Crescendo-decrescendo pattern of nystagmus intensity 2
• Resolution within 60 seconds from nystagmus onset 2, 4
• Subjective rotational vertigo accompanying the nystagmus 1

Critical Testing Protocol to Maximize Diagnostic Yield

Always Test Both Sides

You must perform the Dix-Hallpike on both sides before concluding a negative result, as only testing one side will miss contralateral posterior canal BPPV. 1, 5

Repeat Testing When Initially Negative

If the first Dix-Hallpike is negative but clinical suspicion remains high, repeat the maneuver after testing the horizontal canals. 5, 6

• Holding the patient in various head positions allows canaliths to collect, potentially converting a false-negative to a true-positive result 5
• One study found that repeating diagnostic maneuvers sequentially identified an additional 28 patients (20% increase in diagnostic yield) who were negative on first testing 6

Add Supine Roll Test for Comprehensive Evaluation

After completing bilateral Dix-Hallpike testing, perform the supine roll test to evaluate for lateral (horizontal) canal BPPV, which accounts for 10-15% of BPPV cases. 2, 4

• Lateral canal BPPV can sometimes produce nystagmus during Dix-Hallpike testing, creating diagnostic confusion 7
• Both tests should be interpreted together for accurate diagnosis 7

Common Pitfalls and How to Avoid Them

Pitfall #1: Testing Only Once on Each Side

Failure to repeat the Dix-Hallpike after an initially negative result is the most common reason for missed diagnoses. 5, 6

Pitfall #2: Not Testing Both Sides

Bilateral posterior canal BPPV occurs in approximately 11% of cases, particularly after head trauma. 8

Pitfall #3: Misinterpreting Atypical Nystagmus

• If you observe horizontal nystagmus or spontaneous nystagmus without the characteristic pattern during Dix-Hallpike, this suggests central pathology rather than BPPV 2
• In such cases, brain MRI is indicated, as it detects acute brain lesions in 11% of patients with episodic vertigo and atypical Dix-Hallpike findings 2

Safety Considerations and Contraindications

Exercise extreme caution or avoid the Dix-Hallpike in patients with: 1, 2, 4

• Significant vascular disease or known cerebrovascular 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 specialized tilting examination tables. 2, 4

When Imaging is NOT Needed

Do not order routine vestibular testing or neuroimaging in patients who meet diagnostic criteria for BPPV based on history and positive Dix-Hallpike findings without additional concerning neurologic symptoms. 2

The diagnosis of BPPV is clinical, and unnecessary testing increases costs without improving outcomes. 2