When to use it
- Use for episodic positional vertigo — brief spells (seconds) of spinning triggered by head movement such as rolling over in bed, lying down, or looking up.
- Diagnoses posterior canal BPPV, which accounts for the large majority (~85–90%) of BPPV.
- The patient should be between attacks and reasonably well at rest — BPPV does not cause continuous vertigo.
Not for continuous vertigo. A patient with ongoing spontaneous vertigo and nystagmus at rest has an acute vestibular syndrome — assess with HINTS, not Dix–Hallpike.
Cautions & consent
- Relative cautions: significant cervical spine disease or instability, recent neck trauma/surgery, severe carotid or vertebrobasilar disease, recent retinal detachment, and unstable cardiac disease.
- Where neck extension is unsafe, use a side-lying manoeuvre (e.g. the Semont-type/side-lying test) as an alternative.
- Warn the patient it will briefly provoke their vertigo and often nausea — reassure them it settles within a minute and hold them securely.
Set-up
- Sit the patient lengthways on the couch so that when they lie back their head and shoulders can extend beyond the top edge.
- Position yourself so you can support the head throughout and lower them smoothly.
- Ask the patient to keep their eyes open and look straight ahead so you can watch for nystagmus. Frenzel lenses (or a phone camera) help by removing visual fixation, which otherwise suppresses peripheral nystagmus.
Technique
Turn the head 45° toward the test ear
With the patient sitting upright, rotate the head 45° to one side (start with the side you suspect, or the side of reported triggering).
Lie the patient back briskly
Keeping the 45° rotation, quickly lower them to supine so the head hangs about 20–30° below the horizontal over the edge of the couch. Do it in one smooth, fairly rapid movement.
Observe for up to 30–60 seconds
Watch the eyes closely and ask about vertigo. Note the latency before nystagmus starts, its direction, and how long it lasts.
Return to sitting
Bring the patient back upright, keeping the head turned; a brief reversal nystagmus may occur. Allow symptoms to settle.
Repeat on the other side
Turn the head 45° the other way and repeat to test the opposite posterior canal. Test the asymptomatic side too so you can compare.
Interpreting the response
Positive — posterior canal BPPV
- Latency: nystagmus and vertigo begin a few seconds after reaching the position.
- Direction: transient up-beating and torsional nystagmus, with the upper pole of the eyes beating toward the dependent (lower, affected) ear.
- Duration: paroxysmal — builds then settles within about 30–60 seconds.
- Fatigable: lessens on repeat testing.
- The affected ear is the lower ear in the provoking position.
Central red flags
- No latency — nystagmus immediate.
- Purely vertical (especially down-beating) or purely torsional nystagmus.
- Persistent (does not fatigue or settle) or direction-changing.
- Vertigo out of proportion, or other neurological signs.
Down-beating nystagmus on Dix–Hallpike suggests a central (posterior fossa) lesion, not BPPV — treat as central vertigo, image and refer rather than attempting Epley.
Next steps
- A positive test confirming posterior canal BPPV is treated at the bedside with the Epley (canalith repositioning) manoeuvre.
- If the Dix–Hallpike is negative but the history strongly suggests BPPV, consider horizontal (lateral) canal BPPV and perform a supine roll (Pagnini–McClure) test.
- If features are central, or the patient has continuous symptoms, ongoing nystagmus at rest, or focal neurology, treat as possible posterior circulation stroke.
Supervision pointers
Generic ED skills entrustment levels — not a named curriculum DOPS:
| 1 | Observed only — distinguishes episodic positional from continuous vertigo. |
| 2a | Performs the manoeuvre safely with supervisor present; positions the patient correctly. |
| 2b | Interprets the nystagmus, identifies the affected side and recognises central red flags. |
| 3 | Indirect supervision; links a positive test to Epley and escalates atypical cases. |
| 4 | Independent; teaches the technique and its interpretation. |
References
- Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg 2017;156(3_suppl):S1–S47.
- NICE CKS — Benign paroxysmal positional vertigo.
- Kim JS, Zee DS. Benign Paroxysmal Positional Vertigo. N Engl J Med 2014;370:1138–1147.