Dix-Hallpike Test: Clinical Use, Performance, and Interpretation

Dizziness is a common referral reason across rehabilitation settings, yet it remains one of the more time-intensive symptoms to evaluate. Patients often describe vague sensations, symptoms may fluctuate, and clinicians are expected to determine whether vestibular involvement is present within a limited visit window. Because of this diagnostic complexity, the Dix-Hallpike test is often used as a targeted positional assessment to help narrow the differential efficiently.

When used intentionally, the Dix-Hallpike test helps clinicians identify posterior semicircular canal benign paroxysmal positional vertigo (BPPV) and determine appropriate next steps. In day-to-day practice, clinicians often adapt how the test is performed based on patient tolerance, physical limitations, or safety considerations.

This article reviews what the Dix-Hallpike test assesses, when it is appropriate, how clinicians commonly perform it in practice, and how to interpret findings in a way that supports efficient, patient-centered care.

What is the Dix-Hallpike test?

The Dix-Hallpike test is a positional assessment used to evaluate for posterior semicircular canal benign paroxysmal positional vertigo (BPPV). It works by placing the patient in positions that provoke movement of displaced otoconia within the semicircular canals, allowing clinicians to observe resulting eye movements and symptom responses.

What the test evaluates

The test assesses:

• Positional vertigo triggered by changes in head position

• Direction, latency, and duration of nystagmus

• Patient-reported symptom reproduction

A positive test typically includes both vertigo symptoms and observable nystagmus, though presentation may vary depending on the stage of BPPV and individual patient factors.

One test, adaptable execution

It is important to clarify that the Dix-Hallpike test refers to a single clinical assessment. In practice, clinicians may modify positioning to accommodate cervical limitations, anxiety, or medical complexity while maintaining the same clinical intent and interpretation.

The Dix-Hallpike maneuver is the gold standard positional test for confirming posterior canal BPPV and distinguishing peripheral vertigo from central etiologies.²

When the Dix-Hallpike test is appropriate

The Dix-Hallpike test is most appropriate when a patient’s symptom history points toward posterior canal involvement, rather than as a general screening tool for dizziness. It is intended for patients with paroxysmal, positionally triggered vertigo.¹

Common clinical indicators

The test is typically appropriate when patients report:

• Brief episodes of vertigo lasting seconds that occur suddenly

• Symptoms triggered by rolling in bed, looking up, or lying down

• A clear positional component to dizziness

These features are consistent with peripheral vestibular involvement and help distinguish BPPV from central or cardiovascular causes.¹

When to pause or expand the assessment

The Dix-Hallpike test may not be appropriate as an initial assessment when patients present with:

• Constant or progressive dizziness

• New neurological signs

• Severe headache or visual changes

In these cases, additional screening or referral may be warranted before positional testing, as non-paroxysmal symptoms or neurological findings raise concern for central etiologies that require further evaluation.¹

How clinicians perform the Dix-Hallpike test in practice

While the clinical intent of the Dix-Hallpike test remains consistent, clinicians often adapt positioning to prioritize patient safety, comfort, and diagnostic clarity. The approach selected should reflect both the patient’s symptom presentation and their physical tolerance for positioning.

1. Standard Dix-Hallpike positioning

The standard Dix-Hallpike maneuver is the most widely taught and referenced approach.

Key components include:

• Patient begins seated on the treatment surface

• Head rotated approximately 45 degrees toward the test side

• Rapid transition to supine with cervical extension

• Observation of eye movements for 30 to 60 seconds

This approach is preferred when the patient tolerates cervical extension and rapid position changes.

2. Modified Dix-Hallpike positioning

A modified Dix-Hallpike approach maintains the same clinical intent as the standard maneuver while reducing physical strain or symptom provocation.

Common modifications include:

• Decreased cervical extension

• Slower transitions into supine

• Use of pillows or table adjustments to support the head and trunk

These adaptations are frequently used for patients with limited cervical range of motion, anxiety related to symptom provocation, or medical complexity that warrants a more cautious transition.

Evidence-informed variation: the loaded Dix-Hallpike

One evidence-informed modification, often referred to as the loaded Dix-Hallpike, involves pre-positioning the head or trunk before transitioning to supine in order to encourage otoconia movement toward the posterior canal. Research suggests that this approach may increase test sensitivity and prolong observable nystagmus in some patients with posterior canal BPPV.²

Findings from loaded or modified approaches are interpreted using the same clinical criteria as the standard Dix-Hallpike maneuver.

3. Side-lying Dix-Hallpike approach

The side-lying Dix-Hallpike approach is frequently used when supine positioning or cervical extension is contraindicated. This variation (sometimes referred to in the literature as the Semont Diagnostic Maneuver) assesses the same posterior canal and should not be considered a separate diagnostic test. It provides a practical alternative for patients with orthopedic or vascular concerns.

Typical setup includes:

• Patient begins seated

• Head rotated away from the test side

• Patient transitions directly into side-lying

This diagnostic variation differs from the therapeutic Semont maneuver, which is used for canalith repositioning.

Observation and interpretation across variations

Regardless of positioning, certain observation principles remain consistent.

What clinicians observe

Across all approaches, clinicians assess:

• Presence and direction of nystagmus

• Latency before symptom onset

• Duration of symptoms

• Patient-reported vertigo intensity

Consistency matters

Using consistent positioning when retesting or documenting supports clearer interpretation over time, particularly when multiple clinicians are involved in care.

Interpreting Dix-Hallpike test results

Accurate interpretation of the Dix-Hallpike test depends on integrating observable findings with patient-reported symptoms.

Findings consistent with posterior canal BPPV

Typical findings include:

• Upbeating torsional nystagmus toward the affected ear

• Brief latency before symptom onset

• Symptoms lasting less than one minute

• Fatigue with repeated testing

These findings support a peripheral vestibular source and often guide immediate intervention.

Atypical or inconclusive findings

Some Dix-Hallpike test responses require additional consideration, particularly when findings do not follow typical peripheral patterns. Examples include persistent nystagmus without fatigue, direction-changing or purely vertical nystagmus, or patient-reported vertigo without observable eye movements.

Variability in nystagmus duration or symptom intensity may be influenced by otoconial positioning within the canal, which has been shown to affect the sensitivity of positional testing.²

When findings are atypical or inconclusive, clinicians may consider repeating positional testing to assess consistency, selecting an alternative positional assessment, or expanding the evaluation to include additional vestibular or neurological screening as clinically indicated.

Dix-Hallpike test compared to other positional tests

Positional testing is most effective when the selected test matches the patient’s symptom pattern. While the Dix-Hallpike test is commonly used, it is one of several tools that may be appropriate depending on presentation.

Each test serves a specific purpose. Selection should be guided by symptom history and physical examination findings rather than routine use.

Clinical application of the Dix-Hallpike test

A physical therapist evaluates a 72-year-old patient who reports brief episodes of vertigo when rolling to the right in bed. The patient denies constant dizziness, headaches, or neurological symptoms but has a documented history of cervical arthritis.

After completing a brief cervical screen, the therapist considers whether standard supine testing with cervical extension is appropriate. To minimize strain and improve patient comfort, a side-lying Dix-Hallpike approach is selected.

During testing, the patient reports vertigo after a short latency, and upbeating torsional nystagmus is observed. Based on these findings, the therapist identifies posterior canal involvement and proceeds with an appropriate canalith repositioning maneuver. Education is provided on expected symptom response and follow-up considerations.

This approach allows the clinician to confirm positional vertigo efficiently while adapting assessment techniques to the patient’s physical limitations. In practice, many care teams use the Dix-Hallpike test as part of a stepwise vestibular evaluation, combining targeted history with positional testing to support accurate diagnosis and reduce unnecessary imaging.

Documentation and workflow considerations

At minimum, documentation should reflect the side tested, the positioning approach used, and whether vertigo symptoms were reported and nystagmus was observed. Including the direction and duration of nystagmus, patient-reported symptom latency, and the clinician’s interpretation helps ensure findings are clearly understood by other members of the care team.

Noting the specific Dix-Hallpike variation used is especially helpful when reassessment occurs across visits or providers.

Supporting clinical skill development in vestibular assessment

Clinicians who treat vestibular conditions intermittently often rely on continuing education to maintain confidence with assessment techniques and interpretation. This is especially relevant for positional testing, where small differences in execution or observation can influence diagnostic clarity.

Medbridge’s continuing education is designed to support clinicians across a wide range of practice settings. Our library includes 3,000+ courses and education resources designed to emphasize evidence-based instruction, visual demonstration, and case-based application—supporting strong clinical reasoning and safe adaptation to individual patient needs. 

For clinicians looking to build or refresh skills related to vestibular assessment and BPPV, relevant learning options within our library include:

• Dix-Hallpike, Roll Test, and Epley Maneuver for BPPV, which reviews commonly used positional tests and treatment approaches for posterior canal BPPV, with an emphasis on proper performance and effectiveness.

• Diagnostic Maneuvers for BPPV, which covers posterior and horizontal canal testing, interpretation of findings, and modifications for patients with mobility or positioning limitations.

• What Is Happening With BPPV and Older Adults?, a podcast episode that explores evidence-based screening strategies and clinical considerations when symptom presentation is less reliable.

Applying the Dix-Hallpike test with confidence

The Dix-Hallpike test remains a valuable clinical tool when used intentionally and adapted thoughtfully. Understanding the different ways clinicians perform the test allows for safer, more patient-centered assessment without compromising diagnostic value.

By pairing careful history-taking with appropriate positioning and clear documentation, clinicians can use the Dix-Hallpike test to improve diagnostic clarity and support meaningful patient outcomes.

References

1. Talmud, J. D., Coffey, R., Hsu, N. M., & Edemekong, P. F. (2023, July 19). Dix-Hallpike maneuver. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459307/

2. Andera L, Azeredo WJ, Greene JS, Sun H, Walter J. Optimizing Testing for BPPV - The Loaded Dix-Hallpike. J Int Adv Otol. 2020 Aug;16(2):171-175. doi: 10.5152/iao.2020.7444. PMID: 32784153; PMCID: PMC7419087. https://pmc.ncbi.nlm.nih.gov/articles/PMC7419087/