How do I diagnose and treat an adult with brief positional vertigo episodes suggestive of benign paroxysmal positional vertigo?

Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo

Immediate Diagnostic Approach

Perform the Dix-Hallpike maneuver bilaterally at the initial visit—this is the gold standard diagnostic test for posterior canal BPPV and should be your first step after taking a focused history. 1

Key Historical Features to Elicit

• Episodes lasting less than 1 minute triggered by specific head position changes (rolling over in bed, looking up, bending forward) 2
• "Room spinning" sensation is classic, but patients may alternatively describe lightheadedness, dizziness, nausea, or feeling "off balance"—do not exclude BPPV based on descriptor alone 2
• Timing and triggers are more diagnostically useful than the specific words patients use to describe their symptoms 2
• Approximately 50% of patients report subjective imbalance between classic episodes 2
• Up to one-third of cases with atypical histories will still show positional nystagmus on Dix-Hallpike testing 2

Performing the Dix-Hallpike Maneuver

Technique (must be done bilaterally): 1

1. Starting position: Patient sits upright on examination table, rotate head 45° toward the side being tested to align the posterior semicircular canal with the sagittal plane 2, 1

2. Execution: Quickly lay patient back to supine with head hanging 20° below horizontal, maintaining the 45° rotation 1

3. Observation period: Hold this position for 20-60 seconds while watching for nystagmus and asking about vertigo 1

4. Positive test characteristics: 2, 1

   • Latency of 5-20 seconds (may be up to 1 minute in rare cases) before nystagmus onset
   • Torsional upbeating nystagmus
   • Crescendo-decrescendo pattern
   • Resolution within 60 seconds of onset
   • Accompanying subjective vertigo

5. Repeat on opposite side to determine which ear is affected 1

Diagnostic Accuracy and Pitfalls

• Sensitivity is 82%, specificity is 71%—a negative test does NOT rule out BPPV 1
• Repeat the maneuver at the same visit or a subsequent visit if initial testing is negative but history is suggestive 1
• Do not repeat multiple times to demonstrate fatigability, as this may interfere with immediate treatment 1

If Dix-Hallpike is Negative: Test for Lateral Canal BPPV

Perform the Supine Roll Test when Dix-Hallpike is negative, as lateral canal BPPV accounts for 10-15% of cases and is frequently missed 3

• With patient supine, rotate head 90° to each side 3
• Look for geotropic nystagmus (fast phase toward ground, most common) or apogeotropic nystagmus (fast phase away from ground) 2, 3
• The side with strongest nystagmus is the affected ear in geotropic form; opposite side in apogeotropic form 2

Treatment Algorithm

Posterior Canal BPPV (Most Common)

Perform canalith repositioning maneuvers immediately after diagnosis—these are level 1 evidence treatments with comparable efficacy. 4

Choose one of the following: 4

• Epley maneuver (modified)
• Semont maneuver
• Selection based on clinician preference, patient mobility restrictions, or failure of previous maneuver

Success rate: 91.7% resolution with repositioning procedures 5

Lateral Canal BPPV

Gufoni maneuver is level 1 evidence treatment for horizontal canal BPPV 4

Follow-Up Protocol

Reassess within 1 month after initial treatment to verify symptom resolution or identify persistent/recurrent BPPV 3

When NOT to Perform Dix-Hallpike

Contraindications and cautions: 1

• Significant vascular disease
• Severe cervical stenosis
• Kyphoscoliosis or limited cervical range of motion
• Severe rheumatoid arthritis, cervical radiculopathies, or ankylosing spondylitis
• Down syndrome, Paget's disease, or spinal cord injuries
• Morbidly obese patients (may require specialized tilting tables)

Red Flags Requiring Imaging BEFORE Positional Testing

Do NOT perform Dix-Hallpike if any of the following are present—order urgent MRI brain first: 3

• Positive Romberg test (indicates central pathology)
• Severe postural instability with falling
• Focal neurologic deficits
• Cranial nerve abnormalities
• Age >50 with vascular risk factors and atypical features
• Continuous vertigo lasting days (acute vestibular syndrome)

What NOT to Order

Do not order the following in patients meeting BPPV diagnostic criteria: 1, 3

• Routine imaging (CT or MRI) when typical nystagmus is present and no neurologic red flags exist
• Vestibular testing
• Routine blood work (CBC, chemistry panels)
• Routine audiometry

CT head has <1% diagnostic yield for isolated dizziness and misses posterior fossa strokes 3

Persistent or Recurrent BPPV

If symptoms persist beyond 2 weeks or recur after successful treatment: 5

• Secondary causes (trauma, Ménière's disease, vestibular neuritis) are more common than in typical BPPV 5
• Lateral semicircular canal involvement is most common in persistent BPPV 5
• Treat with frequently repeated canalith repositioning procedures every 2-3 days—86.7% success rate 5
• Consider comorbidities: migraine, persistent postural perceptual dizziness, low vitamin D 4