Dix-Hallpike Test and Epley Maneuver

Benign Paroxysmal Positional Vertigo (BPPV) is due to flakes of calcium in the semicircular canals of the Labyrinth, the part of the inner ear which maintains our sense of balance, disrupting its normal function (see Anatomy of the Ear). The Epley Maneuver (see picture below) aims to maneuver the head in ways to coax those flakes out. The Dix-Hallpike Test is the first part of the Epley (panels A-to-C in the picture).

The structure in the center of the picture represents the semicircular canals, with the green dot being the flake of calcium. The small arrows show how it gets extracted. The larger arrows show how the head is being rotated.

We warn the patient that the Dix-Hallpike part may provoke Vertigo, but we urge the patient to keep their eyes open. We explain that the full Epley can sometimes cure the vertigo right on the spot.

We consider the Dix-Hallpike “positive” if, in panel C below, we observe nystagmus (jerky back-&-forth eye movements, while the patient attempts to focus straight, or to move their eyes horizontally). But even if we don’t see the nystagmus, we continue on through the entire Epley (panels A-to-F).

In panel B, we decide whether to begin by turning the head to the right or left depending on the direction of the vertigo. If the patient’s feels spinning to the right (clockwise), we perform the maneuver starting with head rotated to the right (as in the picture). If spinning is to the left (counterclockwise), we’d begin with head to left.

W proceed as follows (follow the picture below):

A. The patient sits in anticipation

B. We rotate the patientโ€™s head 45ยฐ to the right (we support the head throughout)

C. Abruptly lay them back, head (still rotated) extended off the table (do it in under 2 secs.)
xxxxxโ€ข Hold the position for 30 secs., observing the eyes for nystagmus (= a positive Dix-Hallpike)

D. Rotate the head so it will be tilted 45ยบ to the left.  Hold the position for 30 secs.

E. Roll the person onto their Left side, head turned with nose aiming toward the floor.  Wait 30 secs.

F. Help the patient sit up straight, but with head bent forward, chin on chest (not as in the picture).  xxxxxโ€ข Wait a final 30 secs.

nejm.org

The test finds BPPV 80% of the time by the Dix-Hallpike.  If it’s negative, since BPPV is so common, we make the diagnosis anyway if “Keys to Diagnosis” above suggest it (see Dizziness). 

The Epley maneuver sometimes cures BBPV in a single attempt. More often, it may need to be repeated a few times each day. If Dix-Hallpike was negative in the office (i.e. no nystagmus was observed), and Epley is no help at all after several attempts, repeat the Epley but beginning with the other ear rotated down (panels B & C).

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