Dix-Hallpike Test & Epley Manoeuvre

These are useful general medical manoeuvres that any doctor, nurse or physiotherapist should be able to do given how common dizziness/vertigo is and how easy it is to diagnose and treat benign paroxysmal positional vertigo (BPPV).  

 

Indication

The Dix-Hallpike Test and Epley Manoeuvre are used to test for and treat BPPV, which should be suspected in patients with:

  • true rotatory vertigo (lucid hallucination of room spinning)
  • reproducible symptoms eg on turning over a particular way in bed, or on turning the head one way 
  • short duration of symptoms ie a few seconds
  • older age - common in general medical and primary care patient groups
  • history of head trauma

 

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 serious cervical spine pathology
  • 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 and neck 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
  • Keeping the head at 45 degrees, lie the patient flat in one motion, then gently help the patient place their head over the side of the couch
  • The head should be turned laterally 45 degrees towards you and extended 30 degrees downwards towards the floor
  • The ear you are testing is turned towards the floor ('ear down')
  • Ask the patient to keep their eyes open and observe for rotatory nystagmus for 60 seconds
  • There is a latent period so persevere even if there is no nystagmus for the first 30 seconds
  • Rotatory nystagmus is a positive result for BPPV for the ear that is down 
  • Horizontal or other nystagmus may be indicative of other neurological conditions and may require investigation
  • If tolerated, continue to perform the Epley manoeuvre

Epley Manoeuvre

  • With the head in the finishing position for the Dix-Hallpike Test, wait for any nausea to pass
  • Turn the patient's head 90 degrees away from the affected ear
  • They should end up with their head turned 45 degrees as if you were testing the other ear 
  • Wait 30-60 seconds
  • Ask the patient to roll on to their side, turning away from the affected side and holding their head at the same angle
  • 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
  • Sometimes two or three Epley 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

 

references

Here are two good BMJ Learning videos on the Dix-Hallpike Test and Epley Manoeuvre

Dix & Hallpike (1952) - the original publication

Epley (1992) - the original publication

 

 

Page last reviewed: 23 September 2016