The Dix-Hallpike test remains the gold standard diagnostic test for the diagnosis of benign paroxysmal positional vertigo (BPPV) of the posterior semicircular canal (p-BPPV).

The test is not indicated in patients with an acute vestibular syndrome, and those who are acutely ill with persistent, continuous vestibular symptoms (vertigo, nausea or vomiting, or head motion intolerance).

Redrawn from: Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999;341(21):1590-1596. doi:10.1056/NEJM199911183412107
 

The patient should be warned that they may feel very dizzy, vertiginous, or nauseous, but that they should keep their eyes open no matter how they feel, since observing the eyes is the purpose of the test. (It is a good idea to supply the patient with a basin in easy reach if they have a history of nausea or vomiting with their positional vertigo episodes. Note that vomiting is rare with a single Dix-Hallpike test in BPPV, and its presence should generally prompt consideration of central mimics).

Typically one does the test on the normal side first:

• Patients may be able to report that they become symptomatic when they turn to one side: the affected side is that which results in symptoms when the patient turns to that side.
• Alternatively, performing a Dix-Hallpike test should identify the affected ear (the patient can be instructed to do this themselves before the visit).
   

Step 0 – The test is best performed with Frenzel glasses.
Step 1 – Seat the patient on a table in a position in which they can easily be lowered to the head hanging position with the neck in slight extension. Ask them to fold their arms.

Typically the left side is examined first since that side is less frequently affected than the right side.
Stabilize the head with your hands and move the head 45 degrees toward the side you will test:
Example: for left sided posteior semicircular canal BPPV, patient is examined from the left and head is turned to the left. Note that the head must be turned by 45 degrees before the transition.

(Note that the head is turned by 45° due to the orientation of the vertical semicircular canals within the skull.  If one wishes to examine the right vertical canal the head must be turned by 45° to the right).

Step 2 – Move the head, neck and shoulders en bloc to the head hanging position “expeditiously but carefully”  (should take about 2-3 seconds). The final head position should be hanging back over the edge of the examining table (head hanging position of about 30-40 degrees below the horizontal plane). (If the head is flat on the bed, this could result in a false negative test).
Observe the eyes, holding them open if necessary. Findings are described in the section on posterior canal BPPV.

Step 3 – The patient is next returned to the sitting position with the head facing forward, again observing for nystagmus.

Step 4 – If the initial result is negative, the Dix-Hallpike maneuver should then be repeated for the other side.

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• Confirmation of diagnosis of BPPV prior to use of a canalith repositioning manoeuvre.
• Patients with ongoing, unexplained dizziness, vertigo, or unsteadiness, particularly if their symptoms have an episodic component or one that might be related to changes in head position relative to gravity. The test will identify co-morbid BPPV, associated with pre-existing vestibular disease.
• Identification of central positional nystagmus, suggestive of underlying cerebellar lesions.