Dix-Hallpike Test & Epley Manoeuvre

Indication

The Dix-Hallpike Test and Epley Manoeuvre are used to test for and treat BPPV (specifically the most common form affecting the posterior semicircular canal).  BPPV should be suspected in patients with:

  • true rotatory vertigo (lucid hallucination of room spinning)

  • reproducible symptoms on certain kinds of movements eg on turning over in bed, or on turning the head in one direction

  • short duration of symptoms ie up to 30 seconds

  • history of head trauma or previous viral vestibular neuronitis

 

It can be easier to learn these procedures visually.  There are two good BMJ Learning videos on the Dix-Hallpike Test and Epley Manoeuvre. 

 

PROCEDURE

The Dix-Hallpike Test and Epley Manoeuvre can be performed in one consultation. 

  • You will need an examination couch or firm bed with no headboard

  • You will need assistance if the patient has reduced mobility

  • Explain the procedure and take verbal consent; ensure there are no contraindications such as spinal pathology. Reassure the patient that the test may reproduce their vertigo, but that it will pass quickly.

  • Position the patient so that they are sitting with their legs stretching out in front of them so that, when they lie flat, their head will hang over the top edge of the couch

Dix-Hallpike Test

  • Test one side at a time

  • Stand on the side to be tested and have your assistant on the other side, supporting the shoulders

  • Ask the patient to fold their arms across their chest

  • Turn the patient's head 45 degrees towards you and hold both sides of the head

  • Give the patient a count-down. Keeping the head at 45 degrees, quickly lie the patient flat in one motion, lowering the head 30 degrees below the horizontal. Support the patient's with the head with your hands; some clinicians have the patient's head on their knees.

  • The ear you are testing is the one turned towards the floor

  • Ask the patient to keep their eyes open, but not fixated on a particular point.

  • Observe for torsional, geotropic (towards the floor) nystagmus for 60 seconds. There is a latent period, so persevere even if there is no nystagmus for the first 30 seconds

  • Horizontal or other nystagmus, particularly if there is no latent period, may be indicative of central neurological conditions and may require investigation

  • If the test was positive, proceed directly to perform the Epley manoeuvre once the nystagmus has fully settled.

Epley Manoeuvre

  • With the head in the finishing position for the Dix-Hallpike Test, wait for any nystagmus and vertigo to end. Remember that the affected ear is the one currently facing down.

  • Turn the patient's head 90 degrees to the opposite side, so that the affected ear is now facing upward.

  • Wait 30-60 seconds

  • Ask the patient to roll on to their side so that they are lying on the shoulder opposite to the affected ear, whilst keeping the head turned in the same way relative to their shoulders.

  • You should support their head and help them to roll over

  • They should now be on their side, with the affected ear uppermost, and their head should still be turned at 45 degrees so that they are almost staring at the floor

  • Wait 30-60 seconds

  • Ask the patient to swing their legs over the side of the couch and sit up slowly

  • Support their head in its 45 degree angle as they sit up

  • Wait 30-60 seconds

  • Gently help the patient to turn their head back to the midline and to flex their neck a little

  • Wait 30-60 seconds

  • The patient can slowly bring their head up and move when comfortable

  • They should try to minimise head movement for 24 hours after treatment

  • The Epley manoeuvre is highly effect, but sometimes two or three manoeuvres are required to treat BPPV: it is worth performing one and reassessing a few days later or at the next clinic appointment

  • Rarely, some patients may have bilateral BPPV based on the history: try to judge which side is worse, treat it and then reassess at a later date

  • About 1 in 20 patients has BPPV resistant to repeated Epley Manoeuvres; consider whether another canal could be affected. This requires different tests and manoeuvres.

 

references

Dix & Hallpike (1952) - the original publication

Epley (1992) - the original publication

 

 

Page last reviewed: 9 December 2019