HINTS exam in acute vertigo is a bedside eye-movement examination used by trained clinicians in a specific setting called acute vestibular syndrome: sudden continuous vertigo or dizziness lasting hours to days, usually with nausea, vomiting, spontaneous nystagmus, and gait unsteadiness. It is used to help separate a likely peripheral vestibular syndrome, such as vestibular neuritis, from possible central causes such as posterior circulation stroke.
The key safety point is simple: HINTS is useful only in the right clinical context and only when performed correctly. It is not meant for brief positional vertigo attacks, old dizziness that has settled, or self-checking at home. A normal-looking early CT or MRI can still miss some posterior circulation strokes, so red flags and clinical judgment matter.
Quick routing:
- Brief spinning for seconds when rolling in bed usually needs Dix-Hallpike testing for BPPV, not HINTS.
- Continuous vertigo for hours to days with nystagmus may need a trained HINTS/HINTS+ assessment plus emergency judgment.
- Unclear or recurrent vertigo may need VNG testing, hearing testing, BP/sugar review, medication review, and neurological assessment.
- For patient-facing warning signs, see the vertigo red flag check.
What HINTS stands for
HINTS stands for Head Impulse, Nystagmus, and Test of Skew. Many clinicians also add a hearing check, called HINTS+, because new hearing loss during acute vertigo can change the urgency and differential diagnosis.
| Part | What is checked | Why it matters |
|---|---|---|
| Head impulse | Whether the eyes stay fixed on a target during a quick small head turn | In the right acute vestibular syndrome setting, a normal head impulse can be a central warning sign; an abnormal corrective saccade often points toward peripheral vestibular loss. |
| Nystagmus | Direction and behavior of involuntary eye movements | Direction-changing gaze-evoked nystagmus, vertical nystagmus, or other central patterns need urgent review. |
| Test of skew | Vertical eye misalignment on alternate cover testing | Skew deviation can suggest a central brainstem/cerebellar process. |
When HINTS is appropriate
HINTS is intended for patients with acute vestibular syndrome, not for every person who says they are dizzy. It is most relevant when the patient has continuous vertigo or dizziness, spontaneous nystagmus, nausea or vomiting, and marked imbalance. It is not the right test for short attacks that last seconds and are triggered only by head position; those episodes are usually evaluated with positional tests such as Dix-Hallpike or the supine roll test.
This distinction is important because using HINTS in the wrong patient can create false reassurance or false alarm. A patient with classic BPPV may need canal-specific positional testing. A patient with fainting, chest pain, palpitations, blackouts, or very low blood pressure needs cardiovascular and emergency assessment, not only vestibular testing.
Stroke warning signs during vertigo
Any of the following should push the situation toward urgent emergency assessment, regardless of whether HINTS is planned:
- new weakness, numbness, facial droop, slurred speech, confusion, or double vision
- new severe headache or neck pain with vertigo
- inability to walk, sit, or stand without support
- vertical or direction-changing nystagmus seen by a clinician
- new hearing loss with severe continuous vertigo
- chest pain, fainting, palpitations, or breathlessness
HINTS signs that raise concern for central vertigo
In the correct acute vestibular syndrome setting, the classic central warning pattern is often remembered as INFARCT: Impulse Normal, Fast-phase Alternating nystagmus, and Refixation on Cover Test. In practical language, that means a normal head impulse despite severe continuous vertigo, direction-changing nystagmus, or skew deviation should raise concern for stroke or another central cause.
The opposite can also matter. An abnormal head impulse with a consistent unidirectional peripheral nystagmus pattern and no skew may support a peripheral vestibular syndrome such as vestibular neuritis, but this still depends on the whole clinical picture, vascular risk factors, hearing findings, neurological examination, and examiner skill.
Why HINTS is not a self-test
Patients should not try to use HINTS at home to rule out stroke. The findings can be subtle, and interpretation changes depending on whether the patient actually has acute vestibular syndrome. Even trained clinicians can misinterpret HINTS if the case is outside the correct setting or if the eye findings are subtle.
If symptoms are sudden and severe, the safest patient action is emergency care. For non-emergency recurrent vertigo, an ENT/vestibular assessment can decide whether the pattern fits BPPV, vestibular neuritis, vestibular migraine, central vs peripheral nystagmus, or a non-vestibular cause.
How HINTS fits with CT and MRI
Early CT is poor at excluding many posterior circulation strokes. Early MRI with diffusion-weighted imaging is better, but very early small posterior fossa strokes can still be missed. This is why bedside examination, red flags, vascular risk, timing, hearing symptoms, and repeat or advanced imaging may all matter.
HINTS should be viewed as part of clinical triage, not as a replacement for emergency care or imaging when stroke remains possible. If the clinician is uncertain, or if red flags are present, escalation is safer than reassurance.
Non-emergency next steps
If your dizziness is recurrent but not an emergency, the next step is to describe the pattern clearly: spinning versus faintness, duration, triggers, hearing symptoms, headache, falls, medication use, BP/sugar problems, and whether symptoms are continuous or positional. That history decides whether the priority is positional testing, VNG, hearing tests, migraine review, medication review, cardiac/BP review, or neurology referral.
Call 7393062200 or WhatsApp Dr. Prateek Porwal for non-emergency vertigo evaluation. For active stroke-like symptoms, go to emergency care first.
FAQs
Can I do HINTS on myself at home?
No. HINTS needs trained observation of eye movements and the correct acute vestibular syndrome context. It is not reliable as a self-test.
Does a normal CT scan rule out stroke in sudden vertigo?
No. A normal CT scan does not reliably rule out posterior circulation stroke. Emergency clinicians may still need MRI, repeat assessment, or specialist review depending on the red flags and examination.
Is HINTS for BPPV?
Usually no. BPPV is usually brief positional vertigo and is checked with positional tests such as Dix-Hallpike or supine roll testing. HINTS is for continuous acute vestibular syndrome.
What is the most important patient warning sign?
Any dizziness with weakness, facial droop, double vision, slurred speech, new severe headache, fainting, chest pain, or inability to walk should be treated as urgent.
References
- Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke. 2009;40(11):3504-3510. PubMed: 19762709.
- Kattah JC. Use of HINTS in the acute vestibular syndrome. An overview. Stroke and Vascular Neurology. 2018;3(4):190-196.
- Edlow JA, et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): acute dizziness and vertigo in the emergency department. Academic Emergency Medicine. 2023.
This article is educational and cannot diagnose the cause of acute vertigo. Sudden severe vertigo with neurological, cardiac, fainting, or walking red flags needs emergency care.