What is the role of the Dix-Hallpike (Dix-Hallpike maneuver) test in diagnosing central causes of vertigo?

From the Guidelines

The Dix-Hallpike maneuver is not recommended for diagnosing central causes of dizziness, as it is specifically designed to diagnose benign paroxysmal positional vertigo (BPPV), a peripheral vestibular disorder. For central causes of dizziness, which originate from the brain rather than the inner ear, more appropriate diagnostic approaches include neurological examination, brain imaging (MRI or CT), and other specialized tests 1. Central dizziness typically presents with additional neurological symptoms such as diplopia, dysarthria, ataxia, or weakness, and the dizziness often lacks the characteristic brief, positional nature of BPPV.

Some key points to consider when evaluating dizziness include:

• The presence of atypical features such as lack of nystagmus on provoking maneuvers (eg, Dix-Hallpike) or lack of response to treatment maneuvers (eg, Epley) 1
• The presence of associated auditory or neurological symptoms, which may indicate a central cause of vertigo 1
• The importance of a thorough neurological examination, focusing on cerebellar function, eye movements, and cranial nerves, if central causes are suspected 1

The Dix-Hallpike maneuver may yield atypical responses in central vertigo, such as direction-changing nystagmus or persistent vertigo, but these findings are non-specific and should prompt further investigation rather than being used as primary diagnostic criteria 1. Misdiagnosing central vertigo as peripheral can delay treatment of potentially serious conditions like stroke or multiple sclerosis, making proper diagnostic approach crucial. Therefore, a thorough diagnostic workup, including neurological examination and brain imaging, is essential for patients with suspected central causes of dizziness.

From the Research

Use of the Dix-Hallpike Maneuver for Central Causes of Dizziness

• The Dix-Hallpike maneuver is primarily used to diagnose benign paroxysmal positional vertigo (BPPV) and other peripheral causes of vertigo 2, 3, 4.
• Central causes of dizziness often require urgent treatment and can be distinguished from peripheral causes using the HINTS (head-impulse, nystagmus, test of skew) examination 2.
• The Dix-Hallpike maneuver may not be suitable for patients with central causes of dizziness, as it is designed to diagnose peripheral causes of vertigo 5.
• In some cases, the Dix-Hallpike maneuver may be used in patients with central causes of dizziness, but this can lead to misdiagnosis and increased resource utilization 5.

Contraindications to the Dix-Hallpike Maneuver

• The Dix-Hallpike maneuver is contraindicated in patients with certain neck problems, such as severe cervical spondylosis, prolapsed intervertebral disk, and severe rheumatoid arthritis with cervical instability 6.
• Relative contraindications to the Dix-Hallpike maneuver include back pathology, vertebrobasilar ischaemia, nerve root compression, and medical fitness 6.
• A simple functional assessment of neck mobility can be performed prior to the Dix-Hallpike maneuver to determine if it is safe to proceed 6.

Diagnostic Accuracy of the Dix-Hallpike Maneuver

• The Dix-Hallpike maneuver has a sensitivity of 79% and specificity of 75% for diagnosing BPPV 4.
• The side-lying test, an alternative to the Dix-Hallpike maneuver, has a sensitivity of 90% and specificity of 75% for diagnosing BPPV 4.
• The diagnostic accuracy of the Dix-Hallpike maneuver may be limited in patients with central causes of dizziness, and alternative tests such as the HINTS examination may be more useful in these cases 2, 5.