When the Dix-Hallpike (and everything else) is Negative

Alan Desmond
May 3, 2021

It is not uncommon to have a patient describing a history consistent with current active BPPV, and to have your exams, including Dix-Hallpike tests, be negative. My last post described techniques that can improve the likelihood of a positive test in these patients, but sometimes despite your best efforts, you cannot trigger an episode of positional vertigo in your office. What can you do in this situation?

As I have discussed in earlier blogs, the worst thing you could do is tell the patient that they don’t have BPPV. Chances are they would continue to seek opinions from other specialists who know less about BPPV than you.

You could bring them back for repeat examination in hopes of triggering an episode on a different day. Many years ago I did this. I gave the patient a neck collar and instructed them to minimize head tilt for a few hours before exam time. I found that 40% of those with a negative D-H on initial exam had a positive test on return.

The next step in the process was to determine if there was any benefit to bringing them back, or could we just start a one- week trial of exercises for posterior canal BPPV? If there was a suspect side, we would focus on that. If not, we would recommend home Epley exercises for both sides. On review, 57 of 57 patients in this early study reported complete resolution of position vertigo within days of starting the exercises.

I feel the need to point out that all these patients had undergone a vestibular exam to assure there was no evidence of any other peripheral or central vestibular pathology.


Home Epley as a Test and a Treatment

For patients with either active or resolving symptoms of positional vertigo, and otherwise normal exam, we recommend home Epley exercises as both a test and a treatment. Considering that the first position of the Epley exercise is a self- induced D-H test, performing these exercises allows us to determine:

  1. Are the symptoms still active?
  2. Which side is affected?

If the patient can perform repeated D-H tests over a few days with no vertigo, they are likely resolved or don’t have BPPV, so we ask them to stop after two or three days. If they trigger vertigo, we ask them to pay attention to which side is affected and perform the appropriate exercise for seven days. We ask them to contact us if their symptoms of positional vertigo are not completely resolved in seven days. I word that last sentence emphasizing “positional” vertigo, as many patients have some vague lingering symptoms once the positional vertigo is resolved.


The More You Know

We have developed a five minute long video for our patients detailing the causes and treatments for BPPV. An episode of positional vertigo can be very frightening when the patient is not clear on the cause of triggers.

Unfortunately, because many patients with BPPV seek urgent medical care they end up in an emergency department, where benign inner ear disorders are not necessarily treated effectively. Our hope is that by understanding the source of their symptoms, knowing what treatments are effective, and having tools to self treat if they choose, they can avoid unnecessary trips to the ED.


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