The HINTS exam distinguishes peripheral vertigo from stroke at the bedside.
A three-part bedside examination that distinguishes peripheral vertigo (inner ear) from central causes such as posterior fossa stroke. More sensitive than MRI in the first 24 to 48 hours of acute vertigo.
Medical definition
HINTS stands for Head Impulse, Nystagmus, Test of Skew. Each component tests a different aspect of brainstem and vestibular function. The Head Impulse Test: the examiner rapidly rotates the head 10 to 15 degrees horizontally while the patient fixes on the examiner’s nose. A catch-up saccade indicates a peripheral vestibular lesion — the expected finding in vestibular neuritis. An absent catch-up saccade in a patient with acute severe vertigo is a red flag for a central cause. Nystagmus assessment: peripheral nystagmus is unidirectional, beating the same way in all gaze positions. Direction-changing nystagmus strongly suggests a central lesion. Purely vertical nystagmus is also a central red flag. Test of Skew: the cover-uncover test. A vertical corrective movement of the uncovered eye (skew deviation) indicates central pathology. A peripheral HINTS pattern — positive head impulse, unidirectional nystagmus, absent skew — is reassuring. Any central sign requires imaging and urgent neurology referral.
Why it matters for vertigo
In the first 24 to 48 hours of acute severe vertigo, diffusion-weighted MRI misses posterior fossa strokes in up to 20% of cases. The HINTS exam performed by a trained clinician has sensitivity above 96% for posterior circulation stroke in this window. This makes HINTS the most important clinical skill for anyone evaluating acute vertigo. A patient with a peripheral HINTS pattern can be managed conservatively. A patient with a single central sign needs imaging and neurology the same day, even with a normal MRI.
Where I see this in clinic
I discuss the HINTS exam in most online second-opinion consultations where the patient had an acute severe vertigo episode. The key question is whether that episode was vestibular neuritis or a small posterior circulation stroke. Red flags that make me push for imaging: age over 50, vascular risk factors, occipital headache with the vertigo, any double vision or limb weakness, or a HINTS pattern that was not clearly peripheral. When in doubt, central causes are always ruled out before assuming peripheral.
Related terms
Nystagmus – one of the three HINTS components. Vestibular neuritis – the peripheral diagnosis HINTS helps confirm. VNG – the objective test used after the acute phase settles. Dix-Hallpike test – used when BPPV is suspected rather than neuritis.
Medical Disclaimer: Acute severe vertigo with any neurological sign requires emergency evaluation. Consult Dr. Prateek Porwal directly. WhatsApp: 7393062200.