At the bedside
Diagnosis & positional tests
BPPV is a clinical diagnosis: a focused history, then a positional test that both confirms the disorder and localises the canal and side. No imaging is needed in the typical case.
History — what to ask
Ask what brings the vertigo on, how long each spell lasts, and whether there is any hearing change. Short spinning spells triggered by head movement, with normal hearing, point strongly to BPPV.
The key questions:
- What positions or activities trigger the vertigo?
- How long does each episode last?
- Are there any auditory symptoms (hearing loss, tinnitus, fullness)?
- Any head trauma, recent vestibular neuritis or viral illness, or ear surgery?
A history of trauma or neuritis raises the chance of secondary, multi-canal or bilateral BPPV; poor response to repositioning should prompt re-evaluation.1
A precise history localises the likely canal before you test: posterior-canal vertigo is provoked by lying down or rolling; horizontal-canal vertigo is more intense with horizontal head turns; anterior-canal BPPV is suspected when testing induces downbeat vertigo. Use Frenzel goggles or videonystagmography to see subtle nystagmus.3
Dix–Hallpike test — posterior canal
The reference test for posterior-canal BPPV. From sitting with the head turned 45° to the test side, the patient is laid back into head-hanging. A positive test shows latent, fatigable torsional-upbeat nystagmus beating toward the dependent ear.2 Step through it — the eye panel is synced to each stage: still while seated, then, the moment the head-hanging position is reached, the latency and the torsional-upbeat sign. Toggle the tested side to mirror the whole sequence.
Dix–Hallpike test
Patient sits upright on the couch; the head is turned 45° toward the side being tested (right).
Why: Aligns the posterior canal with the plane of the impending movement.
Supine roll test — horizontal canal
When the history suggests the horizontal canal, the supine roll test rolls the head 90° to each side and reads the nystagmus. Geotropic nystagmus indicates canalithiasis (the stronger side is affected); apogeotropic indicates cupulolithiasis (the weaker side).4
Supine roll test (Pagnini–McClure)
Patient lies supine with the head flexed ~30° forward (on a pillow).
Why: Brings the horizontal canals into the earth-vertical plane so the roll provokes them.
From nystagmus to canal — a classifier
The pattern of nystagmus is the key that unlocks the canal, side and mechanism. Pick what you saw and the classifier returns the likely diagnosis and the manoeuvre to treat it — or flags a central red flag.
What did you see?
Select the nystagmus pattern observed on positional testing.
A teaching aid — confirm the canal and side, and exclude central mimics, before treating.
Key points
- BPPV is diagnosed clinically — history plus a positional test, no imaging in the typical case.
- Dix–Hallpike → posterior canal: latent, fatigable torsional-upbeat nystagmus toward the lower ear.
- Supine roll → horizontal canal: geotropic (canalithiasis) vs apogeotropic (cupulolithiasis).
- The nystagmus direction localises canal, side and mechanism — and selects the manoeuvre.