Benign Positional Vertigo in Emergency Medicine Workup

Updated: Sep 18, 2023
  • Author: Andrew K Chang, MD, MS; Chief Editor: Liudvikas Jagminas, MD, FACEP  more...
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Laboratory Studies

No pathognomonic laboratory test for benign positional vertigo (BPV) exists. Laboratory tests may be performed to rule out other pathology.


Imaging Studies

Currently, no imaging study can demonstrate the presence of otoliths.

Head CT scanning or MRI is indicated if the diagnosis is in doubt.


Other Tests

Although most patients with benign positional vertigo (BPV) have posterior semicircular canal involvement, some patients have horizontal canal involvement. This canal should be suspected if the patient has bilateral symptoms during the Hallpike test. Use the Roll test to formally diagnose horizontal canal BPV, and use the bar-b-que treatment to treat horizontal canal BPV.

Roll test

Have the patient lie in the supine position on the gurney. Unlike the Hallpike test, the head does not need to hang over the edge of the gurney.

Turn the patient's head 90° to one side. The patient should experience a reproduction of symptoms and the presence of horizontal nystagmus. The fast phase should beat toward the earth (geotropic).

Now, turn the patient's head 180° (or 90° to the opposite side). The patient should again experience a reproduction of symptoms and the presence of horizontal nystagmus. The fast phase again beats toward the earth (note that it has changed direction). This is known as direction-changing nystagmus (nystagmus that changes direction based on turning the head) and is different from gaze-evoked nystagmus (which is nystagmus that changes direction depending on where the patient is looking, as in Dilantin toxicity).

Note that no matter which way the head is turned, the patient will develop nystagmus and have reproduction of symptoms; however, one side will be much more symptomatic (and demonstrate stronger nystagmus) than the other side. This is the involved side. Like posterior canal BPV, it is important to know which side is involved since that dictates the starting position for the curative maneuver.

A positive Roll test [5]  should be treated with the bar-b-que treatment (see Treatment and the video below). The head is rotated away from the involved side. 

Bar-b-que maneuver. This maneuver is used to treat horizontal canal benign positional vertigo. In this example, the right horizontal canal is being treated. Each position should be held at least 20-30 seconds.

Head-thrust test (head-impulse test)

The head-thrust test is used to diagnose vestibular neuritis and labyrinthitis. [5]

In this test, the patient is told to look at the examiner's nose. The examiner places both his or her hands on the patient's head and rapidly turns it approximately 10–15° to one side. If the vestibular apparatus is functioning properly, the patient will be able to maintain his or her focus on the examiner's nose. If the vestibular apparatus is not working properly, the patient's eyes will deviate to the side and then quickly jerk back to view the examiner's nose. This jerking eye movement is called a saccade and indicates a positive head-thrust test. As a general rule, a positive head-thrust test rules in a peripheral (and hence benign) cause of vertigo. There are reported cases, however, of positive head-thrust tests in central causes of vertigo. In the author's opinion, this test should not be used liberally and only performed when indicated because a negative head-thrust test is more concerning for a central cause of vertigo.



The Hallpike test, along with the patient's history, confirms the diagnosis of BPV. [6, 5] See Physical for details of this procedure.

The modified Epley maneuver is used to treat posterior canal BPV (see Treatment as well as the video below for a demonstration). [7]

Epley maneuver. In this example, the left posterior semicircular canal is being treated. In this clip, the maneuvers are performed quickly. In a real patient, each position should be held for at least 30 seconds or until resolution of the nystagmus and vertigo.