The Dix-Hallpike test is a diagnostic manoeuvre used to identify benign paroxysmal positional vertigo (BPPV).
The Epley Manoeuvre is used to treat BPPV (usually of the posterior canal) once it has been diagnosed (by the previously mentioned Dix-Hallpike test).
This article provides a step-by-step guide to performing both the Dix-Hallpike test and the Epley Manoeuvre in an OSCE setting.
When is the Dix-Hallpike test indicated?
The Dix-Hallpike manoeuvre is indicated for patients with paroxysmal vertigo in whom BPPV is considered in the differential. These patients experience vertigo in brief episodes lasting less than one minute with changes of head position and return to normal between episodes. Light-headedness or a sensation of nausea might last longer than one minute, however, if the sensation of movement persists for more than one-minute alternative diagnoses should be considered. ¹
Introduce yourself to the patient
Confirm the patient’s details (name and date of birth)
Explain what the examination will involve:
- “Today I’ve been asked to assess you in relation to the dizziness you’ve been experiencing. The first stage involves me moving you from a sitting to lying position briskly on the examination couch. The second stage will involve me holding your head whilst asking you to roll onto your side and then to sit upright.”
- “The aim of these procedures is to potentially diagnose and treat the underlying problem causing your dizziness, however, I can’t guarantee an improvement in your symptoms.”
Check if the patient has any back or neck problems (if so the examination may not be appropriate, given the significant amount of movement involved):
- “Do you have any neck or back problems?”
- “Do you have any pain anywhere currently?”
Gain consent to perform the examination:
- “Do you feel you understand what the procedure involves?”
- “Are you ok for me to perform the procedures I discussed?”
Ensure the patient has someone who can help them get home safely (as patients can often be dizzy after the procedure).
There are some absolute and relative contraindications to the Dix-Hallpike/Epley maneuvres that you should be aware of. ²
- Fractured odontoid peg
- Recent cervical spine fracture
- Atlanto-axial subluxation
- Cervical disc prolapse
- Vertebro-basilar insufficiency
- Recent neck trauma
- Carotid sinus syncope
- Severe neck or back pain
- Recent stroke
- Cardiac bypass surgery within the last 3 months
- Rheumatoid arthritis affecting the neck
- Recent neck surgery
- Cervical myelopathy
- Severe orthopnea
Throughout this sequence of movements, make sure to warn the patient in advance of each step, so that they know what to expect.
1. Ask the patient to sit upright on the examination couch.
2. Adjust the patient’s position so that when supine, their head will hang over the edge of the bed, allowing for head extension below the horizontal plane.
3. Position yourself standing behind the patient (who should be sitting upright on the bed).
4. Turn the patient’s head 45º to one side.
5. Whilst supporting the neck, move the patient from their sitting position to a supine position (in one brisk smooth motion), ensuring their head hangs over the bed 30º below the horizontal plane.
6. Ask the patient to keep their eyes open throughout this process.
7. Inspect the patient’s eyes carefully for evidence of nystagmus for at least 30 seconds.
8. If no nystagmus is observed, the test is then complete for that side and you should carefully sit the patient up.
9. After a short break, the test should be repeated on the other side (turning the patient’s head in the opposite direction in step 4).
If the test is positive, the patient will complain of vertigo and you should be able to directly observe nystagmus.
Be aware that patients often feel very dizzy and nauseated when vertigo is triggered.
Asking the patient to fix their gaze once you’ve established nystagmus will often reduce their symptoms.
You should note the following characteristics of the nystagmus:
The typical findings in BPPV include:
- A 2-20 second latent period followed by the onset of torsional (rotary) or horizontal nystagmus:
- Rotary nystagmus is the most common type and suggests the involvement of the superior semicircular canal
- Horizontal nystagmus suggests the involvement of the lateral semicircular canal
- Nystagmus typically lasts 20-40 seconds
- The nystagmus typically wanes with repeated Dix-Hallpike tests
- Differentiating different types of nystagmus can be clinically challenging. Often patients are referred to an audiologist for further assessment, where special cameras are used to differentiate nystagmus subtypes.
When performing the Epley manoeuvre, each position should be maintained until full resolution of symptoms and nystagmus has been achieved for at least 30 seconds.
1. The Epley manoeuvre typically follows on from a positive Dix-Hallpike test, so we will assume the patient is still positioned lying flat, with the head hanging over the end of the bed, turned 45º away from the midline.
2. Turn the patient’s head 90º to the contralateral side, approximately 45º past the midline (still maintaining neck extension over the bed). Keep the patient in this position for 30 seconds.
3. Whilst maintaining the position of the patient’s head, ask the patient to roll onto their shoulder (on the side their head is currently turned towards).
4. Once the patient is on their side, rotate the patient’s head so that they are looking directly towards the floor. Maintain this position for 30 seconds to a minute.
5. Sit the patient up sideways, whilst maintaining head rotation.
6. Once the patient is sitting upright, the head can be re-aligned to the midline and the neck can be flexed so that the patient is facing downwards (chin to chest). Maintain this position for 30 seconds.
The entire procedure can be repeated 2-3 times if needed, however, this will depend on whether the patient is able to tolerate further manoeuvres (as they often precipitate vertigo).
Closing the consultation
Thank the patient
1. Jonathan D. Talmud; Peter F. Edemekong. Dix-Hallpike Maneuver. Published April 10th 2019. [LINK]
2. British Society of Audiology. Recommended Procedure for Hallpike Manoeuvre. Published in 2014. [LINK]