The traditional teaching is that one must not diagnose benign paroxysmal positional vertigo (BPPV) unless geotropic nystagmus is seen on Dix-Hallpike maneuver. But in the emergency department, we commonly see patients with classic paroxysms of vertigo, classic positional triggers, and yet Dix-Hallpike is normal. What is the basis for the traditional view that requires for the diagnosis of BPPV a positive Dix-Hallpike maneuver?


A critically appraised review found that only one study has “tested the test,” finding a sensitivity of 79% and a specificity of 75% (Halker, Neurologist, 2008). Supporting this is the reporting in a review that repositioning maneuvers were effective in 50-97% of these patients (Alvarenga, Braz J Otorhinolaryngol 2011).


Remember of course that Epley is for posterior canal BPPV. So some of these patients with a history that says BPPV and no confirming tests will have a different canal affected. Go ahead and try Epley but if it does not work, consider testing for alternate canals, or, more simply, refer to otolaryngology.


Take home points:

-Use the Epley maneuver in BPPV without nystagmus

-Refer non-responders to the otolaryngologist for consideration of anterior or horizontal canal variants.


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