Down-beating torsional (head-hang)

A downbeat-torsional burst provoked by a straight head-hang or a Dix-Hallpike, after a short latency and settling within a minute. It is the peripheral mimic of a central positional downbeat, and it is treated with the deep head-hanging maneuver rather than a standard Epley.

The beat direction is what separates it from the common posterior canal. Posterior-canal BPPV beats UP with a torsional component; the anterior (superior) canal beats DOWN with one. Everything else about the timing is the same — a short latency, a crescendo-decrescendo burst inside a minute, and a weaker response on repeat.

The timing is what separates it from a central downbeat, and that is the distinction worth rehearsing. A central positional downbeat classically starts at once, persists while the position is held, and often beats down at rest as well; the anterior-canal beat is paroxysmal, positional and fatigable (von Brevern 2015). A positional downbeat that neither fatigues nor responds to treatment is the one that leaves the BPPV list and goes for a central work-up (see Pure downbeat).

Treatment is the deep head-hanging maneuver described by Yacovino (Yacovino 2009), which reaches the anterior canal plane from a straight head-hang rather than the 45-degree turn an Epley starts from. It is not a reverse Epley: no guideline supports one, and three-dimensional simulation indicates it drives debris the wrong way (Bhandari 2021).