Dix-Hallpike manoeuvre
Diagnostic test for posterior canal BPPV. Tests one side at a time; positive when characteristic upbeating-torsional nystagmus is provoked.
Indication
Any patient with brief positional vertigo, particularly triggered by lying down, looking up, or rolling over in bed. Always performed BEFORE any cervical provocation in the workup of dizziness with neck pain.
Procedure
Step 1 of 6Patient sits upright
Patient is seated on the examination couch with their legs extended, so that when they lie back their head will be off the end of the couch (you support the head). Warn the patient that the manoeuvre may briefly provoke their symptoms.
Expected finding
Positive for posterior canal BPPV when, after a 1–5 second latency, the patient develops upbeating-and-torsional nystagmus (top pole of eye beating toward the lower ear) lasting <60 seconds and fatiguing with repetition, accompanied by the patient's characteristic vertigo.
Cautions
- Cervical instability or recent cervical fracture — use modified side-lying technique instead.
- Severe cervical osteoarthritis with limited extension — reduce extension to comfort, or use a half-Dix-Hallpike.
- Carotid bruit or known severe vertebrobasilar disease — relative caution; sustained head rotation should be brief.
- Acute cervical pain that the manoeuvre would worsen — defer until cervical irritability has settled, or use Side-Lying test.
References
- Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017). Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology — Head and Neck Surgery, 156(3 Suppl):S1–S47. link
- von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, Newman-Toker D (2015). Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research, 25(3–4):105–117. link