Dix-Hallpike Test: How to Perform It and Interpret Results for BPPV

Published October 17, 2026 Read time 5 min read Readers 62
Dix-Hallpike Test

The Dix-Hallpike test, also called the Dix-Hallpike maneuver, is the standard bedside provocation test for benign paroxysmal positional vertigo (BPPV). It was described by Dix and Hallpike in 1952 [1]. The test reproduces the patient’s vertigo and shows the clinician the characteristic eye movements (nystagmus) caused by displaced otoconia in the inner ear.

BPPV is the most common vestibular disorder in adults. The American Academy of Otolaryngology–Head and Neck Surgery guideline gives a strong recommendation to diagnose posterior semicircular canal BPPV when the Dix-Hallpike maneuver provokes vertigo with nystagmus [2].

What Is the Dix-Hallpike Test Used For?

The test identifies BPPV that affects the posterior semicircular canal. It is the most common form of the condition. It is indicated in patients who report brief spinning episodes triggered by head position changes, such as:

  • rolling over in bed
  • looking up
  • bending forward
  • lying down or sitting up quickly

How to Perform the Dix-Hallpike Maneuver

The patient sits on an examination table and the clinician stands at the head of the table. The guideline describes the maneuver as bringing the patient from upright to supine with the head turned 45° to one side and the neck extended about 20°, with the tested ear down [2]. Some sources describe the neck as extended roughly 20–30° below horizontal, so the exact angle varies slightly between texts.

Steps

  1. Seat the patient on the table and turn the head 45° toward the side being tested.
  2. Quickly lower the patient to a supine position, keeping the head turned and the neck extended over the edge of the table.
  3. Hold the position and watch the eyes for nystagmus. Ask the patient to report any vertigo.
  4. Return the patient to the upright position and watch again for any reversal of nystagmus.
  5. Repeat on the opposite side. Always test both ears, even if the patient reports symptoms on one side only.

Stop the maneuver and consider further evaluation if the patient develops neurological symptoms during testing. Ask about neck or spine problems beforehand.

Interpreting the Results

Positive test. A positive test combines two findings: the patient reports reproduction of vertigo, and the clinician observes nystagmus. In posterior canal BPPV the nystagmus is:

  • Torsional and upbeating, with the fast phase beating toward the lower (affected) ear [2]
  • Delayed in onset, usually by a few seconds (the latency period)
  • Short-lived, typically lasting less than a minute (about 10–20 seconds in many cases)
  • Fatigable, meaning vertigo and nystagmus usually lessen on repeat testing
  • Reversible, since brief nystagmus in the opposite direction may appear when the patient sits up

The ear that is down during a positive test is the affected side [2].

Negative or atypical test. If the patient has a history compatible with BPPV but the test shows no nystagmus or horizontal nystagmus, the guideline recommends a supine roll test to assess for lateral (horizontal) canal BPPV [2]. Diagnostic criteria for the BPPV variants are set out in the Bárány Society consensus [3].

Next Steps After a Positive Test

A positive Dix-Hallpike test confirms the diagnosis. Canalith repositioning maneuvers, such as the Epley maneuver, are the first-line treatment [2]. A Cochrane review found that the Epley maneuver is effective for posterior canal BPPV [4]. The guideline advises against routine imaging or vestibular testing in patients who meet the diagnostic criteria for BPPV, unless other signs or symptoms point to a different cause [2].

For related clinical tests and maneuvers, see the musculoskeletal and neurological examination guides on Orthofixar.com.

Research Limitations

Reported sensitivity of the Dix-Hallpike test varies between studies. Examiner technique, timing of the exam, and patient selection all affect results, so a negative test does not completely exclude BPPV. Findings should always be read alongside the history and clinical judgment. This article is for education and does not replace professional medical advice.

Frequently Asked Questions

What is the Dix-Hallpike test used to diagnose?
It diagnoses BPPV, most commonly posterior semicircular canal BPPV, by provoking vertigo and nystagmus [2].

What does a positive Dix-Hallpike test look like?
The patient experiences vertigo and the clinician sees torsional, upbeating nystagmus after a short delay, usually lasting under a minute.

Which ear is affected if the test is positive?
The ear positioned downward when vertigo and nystagmus occur is the affected ear [2].

Why is the nystagmus delayed?
There is typically a latency of a few seconds before nystagmus begins, followed by a burst that fades.

Why does the test get weaker when repeated?
BPPV nystagmus is fatigable, so vertigo and nystagmus commonly decrease on repeat testing.

Do both ears need to be tested?
Yes. Always test both sides, even if symptoms are reported on one side only.

What if the Dix-Hallpike test is negative but BPPV is still suspected?
A supine roll test should be done to check for lateral canal BPPV when the history fits and the Dix-Hallpike shows horizontal or no nystagmus [2].

Is imaging needed after a positive Dix-Hallpike test?
Not routinely. Imaging is not recommended when the patient meets BPPV criteria and has no features suggesting another cause [2].

What is the treatment for a positive test?
Canalith repositioning maneuvers such as the Epley maneuver are first-line treatment [2,4].

References

  1. Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med. 1952;45(6):341-354. PubMed.
  2. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. doi:10.1177/0194599816689667. PubMed PMID: 28248609.
  3. von Brevern M, Bertholon P, Brandt T, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. J Vestib Res. 2015;25(3-4):105-117. PubMed.
  4. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162. PubMed.
  5. Orthofixar.com. Dix-Hallpike Test and Maneuver (orthofixar.com).