BPPV Diagnostic Criteria

bppvLast week’s blog covered two recent studies indicating that BPPV is far more common than most patients or physicians realize. As I have written previously, I suspect this is largely the result of lack of appropriate testing in the Primary Care and Emergency Medicine arenas. Many patients with BPPV never undergo the Dix-Hallpike test as recommended in the Clinical Practice Guideline for BPPV that was sponsored by the American Academy of Otolaryngology. The guideline also pointed out that a negative Dix-Hallpike does not mean the patient does not have active BPPV. We felt the need to add this because many practitioners have been taught that a Dix-Hallpike exam must be positive (triggering vertigo and nystagmus) to make the diagnosis of BPPV.

In his seminal paper, Dr. John Epley (yes, that John Epley) describes a “classic” BPPV response to the provocative Dix-Hallpike maneuver as follows: “nystagmus characterized by predominantly rotatory motion with the fast phase directed toward the undermost side, latency, limited duration, reversal on return to upright, and response decline with repetition of the provocative maneuver.” {{1}}[[1]]Epley, J. (1992). The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg, 107(3), 399-404[[1]]

So, what do you do with a patient who presents with a history suggestive of BPPV, yet all vestibular exams, including the Dix-Hallpike are negative?

You could tell him/her the ENG is normal –that it must not be his/her ears. In my opinion, that would be the worst option because the person would seek help elsewhere, with a different specialty. And, as a vestibular specialist, if you misdiagnose BPPV, it is likely that a PCP or other non-ear specialist will also miss it. The patient may not seek another opinion from an ear or vestibular specialist, because you told them it wasn’t their ears – and they believed you.

You could go ahead and do a Canalith Reposition Procedure (CRP) despite the negative exam, but you would be guessing at which ear and which canal. The one thing you would know is that if the patient does in fact have BPPV, the otoconial debris is dispersed (fatigued), and that is the worst time to do a CRP.

You could ask the patient to return for another Dix-Hallpike exam on another day, after restricting head movement (as we did in 2002). This may be reasonable, but I believe it is not necessary.

Next week I will describe a little experiment we did with patients fitting this description.

Photo courtesy of https://www.med.unc.edu/ent/adunka/for-patients/symptoms-disorders/benign-paroxysmal-positional-vertigo-bppv

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.


  1. We published papers exactly on the above topics, on BPPV without nysatgmus, which according to our opinion is even more frequent as classical bppv:

    Benign paroxysmal positional vertigo–toward new definitions.
    Büki B.
    Otol Neurotol. 2014 Feb;35(2):323-8

    J Neurol Neurosurg Psychiatry. 2011 Jan;82(1):98-104. doi: 10.1136/jnnp.2009.199208.
    Sitting-up vertigo and trunk retropulsion in patients with benign positional vertigo but without positional nystagmus.
    Büki B1, Simon L, Garab S, Lundberg YW, Jünger H, Straumann D.

    Best regards


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