The Dix-Hallpike Test: How to Diagnose BPPV at the Bedside
Author: Will Bierrum, Neurology Specialty Registrar
What is BPPV?
Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo, accounting for approximately 20–25% of all patients presenting with dizziness. It affects older adults most frequently, with peak incidence in the mid-sixties, and is nearly twice as common in women as in men.
BPPV is a mechanical disorder of the inner ear. Calcium crystals (otoliths) become dislodged from the utricle and settle in the gravity-dependent parts of the inner ear, most commonly the posterior semicircular canal. When the patient changes head position relative to gravity, these crystals shift and abnormally stimulate the canal's endolymph fluid and cupula, triggering brief, intense episodes of rotary vertigo typically lasting under a minute.
Classic precipitating movements include rolling over in bed, looking upward, or bending forward.
Key fact: BPPV is highly treatable. Physical particle repositioning procedures - the Epley or Semont manoeuvre - resolve symptoms in 80–90% of cases.
What is the Dix-Hallpike Test?
The Dix-Hallpike manoeuvre is the gold-standard bedside test for diagnosing posterior canal BPPV. It is simple to perform, requires no specialist equipment and can be done in any clinical setting. It is also an essential skill to learn for assessing patients presenting with acute vertigo. Unfortunately in clinical practice, I personally see many clinicians who don’t feelt comfortable doing the test, despite it being fairly straightforward.
How to Perform the Dix-Hallpike Test: Step-by-Step
Sit the patient on the examination couch and ask them to remove their glasses. Warn them that the test may provoke intense dizziness, this is expected and short-lived.
Ask the patient to keep their eyes open and fix their gaze on you throughout.
Turn the patient's head 30–45 degrees toward the side being tested.
In a smooth, controlled movement, lower the patient back into a lying position so that their head hangs 20–30 degrees over the edge of the couch (neck hyperextension). This does not need to be rushed or forced.
Observe the eyes carefully for nystagmus for up to one minute.
Clinical tip: Patients who have had the test before may be reluctant to repeat it. Take time to explain what will happen and establish rapport before proceeding. Good communication makes the test easier for both patient and clinician.
What Does a Positive Dix-Hallpike Look Like?
A positive test for posterior canal BPPV produces a highly characteristic nystagmus pattern with five key features:
Latency — Vertigo and nystagmus do not begin immediately. There is typically a delay of 2–20 seconds after reaching the lying position.
Direction — The eyes display a rotary-vertical (upbeat) nystagmus, with the fast phase twisting toward the undermost (affected) ear. Watch the blood vessels on the sclera to identify the direction of rotation clearly.
Short duration — The nystagmus builds and then fades, disappearing completely within 60 seconds (often within 10–40 seconds).
Reversal — When the patient sits back up, vertigo and nystagmus may briefly recur in the opposite direction.
Fatiguability — If the manoeuvre is repeated, the intensity of both the vertigo and nystagmus visibly diminishes.
Any nystagmus that does not fit this pattern, particularly nystagmus that is purely vertical, purely horizontal, direction-changing, or non-fatigable should prompt consideration of a central cause and warrants further investigation.
What Happens After a Positive Dix-Hallpike?
A positive Dix-Hallpike leads directly to treatment. The Epley manoeuvre is the most commonly used repositioning procedure and can be performed immediately following diagnosis. The Semont manoeuvre is an effective alternative. Both work by moving the dislodged crystals out of the posterior canal.
Watch the Dix-Hallpike Test in Practice
In this video, the Dix-Hallpike is demonstrated from the patient's perspective - so you can understand exactly what the patient experiences and feel more confident performing it in your own practice. If you feel reluctant to try it on a patient after watching this, give it a go on yourself (as long as its safe) or try it out on a colleague. After a couple of attempts, it will soon seem easy.
A video showing how to do the Dix-Hallpike maneuvre and how to interpret the findings
Can't hang the patient's head off the couch? Use the side-lying technique.
In busy clinical settings such as emergency departments, small clinic rooms, or with patients who have limited neck extension the standard Dix-Hallpike can be difficult to perform safely. The side-lying variant solves this.
The patient sits upright with their hands on their chest. The head is turned 45 degrees away from the ear being tested, then the patient is lowered sideways onto the tested side. For example, if testing the right ear the patient looks 45 degrees to the left, then goes down onto their right side. The head remains in the same rotated position throughout. You are looking for the same characteristic nystagmus: torsional and upbeat, with the vertical component beating toward the forehead and the torsional component having the top of the eyes beating counter-clockwise from the patient's perspective when testing the right ear. The nystagmus should appear after a brief latency and resolve within 60 seconds. Any nystagmus that does not fit this pattern - particularly nystagmus that is purely horizontal, purely vertical downbeat, direction-changing, or non-fatigable should raise concern for a central cause and warrants further investigation.
If positive, treatment follows immediately using the modified Semont manoeuvre - the patient's head stays in position as they are supported across to the opposite side, the tested ear will now be higher up than the opposite ear and the patient's face will be going towards the couch.
The key advantage is that the whole sequence can be performed on a standard hospital bed without any specialist equipment. For clinicians working outside neurology, this makes BPPV genuinely manageable wherever the patient presents.
Watch the side-lying Dix-Hallpike and modified Semont manoeuvre demonstrated in full below.
Frequently Asked Questions
What is the Dix-Hallpike test used for? The Dix-Hallpike test is used to diagnose posterior canal BPPV — the most common cause of positional vertigo. It identifies the characteristic nystagmus pattern produced when dislodged otolith crystals shift within the inner ear.
How do you perform the Dix-Hallpike manoeuvre? The patient is seated, their head is turned 45 degrees to the side being tested, and they are then rapidly lowered into a supine position with the head hanging 20–30 degrees over the edge of the couch. The examiner observes for nystagmus for up to one minute.
What is a positive Dix-Hallpike result? A positive result shows rotary-vertical nystagmus with a latency of 2–20 seconds, duration under 60 seconds, reversal on sitting up, and fatiguability on repeat testing.
What is the difference between BPPV and other causes of vertigo? BPPV is positional, brief, and associated with a normal neurological examination. Central causes of vertigo are more likely to produce persistent nystagmus, non-fatigable responses, or other neurological signs.
How is BPPV treated? BPPV is treated with particle repositioning manoeuvres — most commonly the Epley or Semont manoeuvre — which resolve symptoms in 80–90% of cases.
Can any clinician perform the Dix-Hallpike? Yes. The Dix-Hallpike is a bedside test that can be performed in any clinical setting with practice. Familiarity with the expected findings is key to interpreting the result correctly.
Summary
BPPV is the most common cause of vertigo, affecting 20–25% of patients presenting with dizziness.
It is caused by calcium crystals displaced into the posterior semicircular canal.
The Dix-Hallpike test is the bedside standard for diagnosing posterior canal BPPV.
A positive result shows latent, short-duration, fatigable, rotary-vertical nystagmus.
Treatment with the Epley or Semont manoeuvre is effective in 80–90% of cases.
Any atypical nystagmus pattern should raise suspicion for a central cause.
Explore the Neurology Pattern Recognition Guide at medxstart.co.uk.
This post is for educational purposes only and does not constitute clinical advice. Always use clinical judgement in individual patient assessment.
Written by Will Bierrum, Neurology SpR and founder of Medxstart - helping clinicians build pattern recognition in neurology.