Whether one is a seasoned clinician or a developing medical student, dizziness can be difficult to diagnose and treat. It affects people of all age ranges with varying degrees of symptoms and severity.  Additionally, dizziness can be difficult for patients to describe, as it can mean different things to different people.  When a patient complains of “dizziness,” they could be describing vertigo, pre-syncope, balance issues, or giddiness.   This difficulty in communication can result in frustration for both the patient and the physician; however, differentiating these symptoms is critical for the clinician to treat the patient effectively. One critical step for clinicians is to characterize dizziness as “central vs. peripheral.” Dizziness can account for approximately 5% of walk-in clinics and roughly 4% of emergency department visits.[1] 

The differential diagnosis for dizziness encompasses numerous body systems, such as neurological, cardiovascular, or hematologic. Some studies have shown up to 15% of cases of dizziness in the ED are life-threatening.[1] Therefore, it is important to perform a thorough history, and physical exam as the ultimate diagnosis can be benign or life-threatening.

Symptoms and disease definitions are essential for professional communication between providers, whether they treat patients in the clinic, emergency department, or inpatient setting. The language utilized to describe terms such as ”dizziness” or ”vertigo” can often mean many different things based on one’s interpretations. Therefore, a committee was formed to promote the classification of vestibular disorders. Below are several definitions from the Committee for Classification of Vestibular Disorders to clarify these symptoms.

1. Vertigo: A sensation of self-motion when in reality, there is no motion occurring or a perceived sense of motion during a normal head movement[2]
2. Dizziness: A sensation of impaired or distorted sense of motion relative to spatial orientation[2]

The canalith repositioning maneuver (CRP) was coined by Dr. John Epley in response to the need for non-invasive treatment for benign paroxysmal positional vertigo (BPPV).[3] Prior to the use of CRP, BPPV was often treated surgically. Following the diagnosis of BPPV, the Dix-Hallpike maneuver can localize the otolith. This manuscript will not detail how to perform the Dix-Hallpike maneuver; however, once the otolith is localized, the next step is to perform the CRP (Epley) maneuver. Of note, the endpoint of the Dix-Hallpike maneuver is the beginning of the Epley maneuver; thus, it is imperative to know how to perform both to be effective in diagnosing and treating BPPV correctly.

BPPV is among the most common inner ear disorders that cause dizziness or vertigo.[4] The disease process appears to be caused by otoliths that become displaced in the semicircular canal.[5] The majority of these otoliths can be found in the posterior semicircular canal, followed by horizontal (lateral).[5] 

These otoliths move due to gravity as the head is turning and cause inappropriate signaling that the head is moving when, in reality, it is not. When the vestibular apparatus, semicircular canals, and visual system are in disequilibrium, it elicits the sensation of dizziness. The classic symptoms of BPPV often involve brief episodes of rotational vertigo that is reproducible.[6]

The most common cause of BPPV is primary or ”idiopathic” as BPPV itself is often found in isolation. However, other inner ear pathologies such as Ménière’s disease and even migraines have links to BPPV.[7][8] Other common causes include head trauma and inner ear surgeries, which can often dislodge otoliths into the semicircular canals.

History and physical exams are pertinent in diagnosing BPPV correctly. The classic symptoms of BPPV often include sudden onset vertigo, worsened by head movements. These attacks can last for under one minute. However, patients have described them lasting much longer due to associated nausea and disequilibrium.

When the clinician has diagnosed BPPV, the clinician has likely ruled out more dangerous etiologies of dizziness; it is crucial to communicate with the patient to assuage their fears because many patients present concerned about the more dire causes of dizziness,  such as an intracranial mass or a stroke. Following a thorough history and physical exam, and the dizziness determined to be secondary to a peripheral cause, the Dix-Hallpike maneuver can be an option. If the etiology of the dizziness is unknown or if a central lesion is a consideration, other physical exam maneuvers such as the HiNTS exam should be employed to further aid in narrowing the differential diagnosis.

There are relatively few contraindications to the Dix-Hallpike maneuver; however, providers need to consider the patient’s physical anatomy and neck mobility concerning their ability to tolerate the quick actions and movements required to perform the maneuver. Patients with cervical spinal stenosis or limited cervical mobility may not tolerate the procedure well due to the quick cervical spine rotation and hyperextension needed for success.[9] 

In a small study of 50 emergency physicians, barriers that contributed to decreased use of either the Dix-Hallpike maneuver or Epley maneuver included negative experiences associated with performing it, forgetting how to perform the maneuver, or relying on a history of present illness to diagnose BPPV. Overall, these physicians still had positive experiences with utilizing the Dix-Hallpike or Epley maneuvers.[10]

The absolute equipment required includes:

• Examination table

Optional equipment and materials include:

• IV access equipment
• Premedication with antiemetics such as ondansetron, promethazine, or meclizine
• Emesis bag
• Pillow positioned under the shoulders for hyperextension of the neck

Using antiemetics before the Epley maneuver can provide comfort and temporary relief of nausea and emesis associated with the maneuver.