Dix-Hallpike Test

The Dix-Hallpike test is a clinical examination method used to diagnose benign paroxysmal positional vertigo (BPPV) – one of the most common causes of dizziness. The condition occurs when small calcium carbonate crystals (otoliths or canaliths) detach from the utricle and migrate into the semicircular canals of the inner ear¹. This causes abnormal stimulation of the vestibular system during certain head movements, leading to short, intense vertigo episodes.

The Dix-Hallpike test was first described in 1952 by neurologist Margaret Dix and otologist Charles Hallpike and remains the most precise diagnostic test for BPPV².

Neurophysiological Background

The vestibular system of the inner ear includes three semicircular canals that detect rotational movements. When otoliths enter these canals, the hair cells in the cupula respond abnormally to head position changes. This sends false signals to the brain and triggers vertigo.

The Dix-Hallpike test provokes this mechanism by positioning the head and body to move the loose particles, while observing eye movements (nystagmus) to confirm diagnosis.

Indication

The test is specifically designed to confirm or exclude posterior or anterior BPPV (vertical canals) and is indicated when patients present with:

• Brief vertigo triggered by head movement (e.g., rolling in bed, lying down)

• Vertigo without neurological deficits

• Suspicion of inner-ear vestibular dysfunction

Test Procedure

Starting position:

• Patient sits upright on the examination table with legs extended.

• Head is rotated 45° toward the test side.

• Examiner stands behind and supports the patient’s head.

Movement into supine:

• Patient is rapidly but safely laid back into supine with the head extended about 30° beyond the edge of the table.

• Head remains rotated 45° toward the test side.

• Examiner supports the head throughout.

Observation:

• Patient keeps eyes open and looks at the examiner.

• Examiner observes for:

  • Nystagmus: direction, latency, duration, and intensity

  • Vertigo symptoms: dizziness, nausea, discomfort

The test is then repeated on the opposite side after a brief pause.

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Interpretation of Results

Positive test:

• Vertigo and nystagmus appearing after a short latency, lasting up to 30 seconds, often accompanied by nausea.

Nystagmus characteristics:

• Posterior canal BPPV: Upward and torsional nystagmus toward the tested side.

• Anterior canal BPPV: Downward and torsional nystagmus.

Negative test:

• No vertigo or nystagmus → BPPV unlikely.

• Consider alternative diagnoses: vestibular neuritis, central vertigo, migraine³.

Clinical Value and Accuracy

• Sensitivity: up to 88% for posterior BPPV⁴.

• Highly specific when performed correctly.

• Allows immediate transition to treatment, e.g., Epley maneuver.

Advantages:

• Non-invasive

• Quick (<5 minutes)

• Direct observation of response

Limitations / Precautions:

• Contraindicated in acute neck or spine injury, recent stroke, aortic stenosis, or pregnancy⁵.

• Can provoke strong symptoms (nausea, vomiting, anxiety).

• Risk of false negatives if performed too quickly or with incorrect head extension.

Dix-Hallpike vs. Epley Maneuver

• Dix-Hallpike test: Diagnostic – reproduces vertigo/nystagmus.

• Epley maneuver: Therapeutic – repositions otoliths back into the utricle.

It is crucial to use the Dix-Hallpike for diagnosis before initiating treatment.

Summary

The Dix-Hallpike test is the gold standard clinical test for diagnosing BPPV. It provokes vertigo and nystagmus by repositioning the head, confirming involvement of the vestibular system. The test is fast, reliable, and essential for guiding further management, including repositioning maneuvers. Proper technique and careful interpretation of nystagmus patterns are key for diagnostic accuracy.

Sources:

1. Hizal E, Jafarov S, Erbek SH, Ozluoglu LN. Clinical Interpretation of Positional Nystagmus Provoked by both Dix-Hallpike and Supine Head-Roll Tests. J Int Adv Otol. 2022 Jul;18(4):334–339. Hentet fra: https://pubmed.ncbi.nlm.nih.gov/35894530/ (Sist brukt: 05.07.2025)

2. Imai T, Inohara H. Benign paroxysmal positional vertigo. Auris Nasus Larynx. 2022 Oct;49(5):737–747. Hentet fra: https://pubmed.ncbi.nlm.nih.gov/35387740/ (Sist brukt: 05.07.2025)

3. Talmud JD, Coffey R, Edemekong PF. Dix Hallpike Maneuver. I: StatPearls [Internett]. Treasure Island, FL: StatPearls Publishing; 2022. Hentet fra: https://www.ncbi.nlm.nih.gov/books/NBK459307/ (Sist brukt: 05.07.2025)

4. Yu J, Meng G, Xu S, et al. Association between Dix-Hallpike test parameters and successful repositioning maneuver in posterior semicircular canal benign paroxysmal positional vertigo: a case-control study. Ann Transl Med. 2020 Mar;8(6):286. Hentet fra: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186607/ (Sist brukt: 05.07.2025)

5. Zheng Y, Wu S, Yang X. Analysis of Dix-Hallpike maneuver induced nystagmus based on virtual simulation. Acta Otolaryngol. 2021 May;141(5):433–439. Hentet fra: https://pubmed.ncbi.nlm.nih.gov/33557660/ (Sist brukt: 05.07.2025)