Emergency symptoms: do not use HINTS to decide whether to wait
Sudden weakness, facial droop, speech difficulty, new severe imbalance or inability to walk, double vision, fainting, chest pain, severe new headache, or other new neurological symptoms may be an emergency. Seek help from local emergency services or the nearest emergency department. Do not wait for a clinic reply or try a HINTS examination at home.
What is the HINTS examination?
HINTS stands for Head Impulse, Nystagmus and Test of Skew. It is a bedside eye-movement examination used by a trained clinician in a specific acute dizziness pattern. It is not a general test for every type of dizziness or brief positional spinning.
The examination is one part of a wider assessment. A clinician also considers the timing and pattern of symptoms, walking ability, hearing symptoms, neurological examination, medical history, medicines, and stroke risk. Imaging or other tests may be needed depending on the clinical situation.
When might a clinician use HINTS?
HINTS may be considered when a person has sudden, persistent dizziness or vertigo lasting hours to days with features of acute vestibular syndrome, such as spontaneous nystagmus, nausea or vomiting, and difficulty walking. It is not designed as a self-check, a video check, or a routine test for brief dizziness triggered by rolling in bed or looking up.
Only a trained clinician can decide whether HINTS is appropriate and whether its findings can be interpreted reliably. A result from an unsuitable situation, or a result assessed without the necessary clinical training, can be misleading.
The three observations a clinician assesses
Head impulse
The clinician observes how the eyes maintain focus while making carefully controlled head movements. The report may describe the clinician’s observation of the vestibulo-ocular reflex. This is not a movement that patients should try to reproduce or score themselves.
Nystagmus
Nystagmus means involuntary eye movement. A clinician records its characteristics as part of the examination. Eye movements can be subtle, and the meaning depends on the complete assessment rather than on a patient watching their own eyes in a mirror or video.
Test of skew
The clinician assesses eye alignment as one part of the examination. This finding needs professional interpretation alongside the other HINTS observations and the neurological examination.
Some clinicians also assess hearing in the appropriate setting; this is often called HINTS Plus. It does not turn HINTS into a home test or a stand-alone diagnosis.
How clinicians use peripheral-compatible and central-concerning patterns
In the right clinical setting, trained clinicians use the complete HINTS pattern to help distinguish a likely peripheral inner-ear cause from a central cause that needs urgent evaluation. A peripheral-compatible pattern does not mean that a patient can safely dismiss new severe symptoms. A central or unclear pattern does not by itself name the final diagnosis; it tells the treating team that urgent assessment, and sometimes imaging, may be needed.
No single HINTS observation should be read as proof of an inner-ear problem or proof of stroke. The result is interpreted with the person’s symptoms, neurological examination, walking and balance, hearing, medical history, risk factors, and the treating team’s judgement.
How HINTS fits with scans
CT, MRI, and other tests have different roles in acute dizziness. The need for a scan, the type of scan, and its timing are decisions for the emergency or treating team. HINTS should not be used by a patient to decide whether imaging is unnecessary, and no online guide can replace emergency assessment when warning symptoms are present.
Related HINTS guides
- For a guide focused on central or concerning findings in acute vertigo, read HINTS Exam in Acute Vertigo: Stroke Signs and Limits.
- For help understanding the terms in a clinician’s report and preparing for assessment, read Understanding a HINTS Examination Report: A Patient Preparation Guide.
References
- Society for Academic Emergency Medicine. GRACE-3: Acute Dizziness and Vertigo in the Emergency Department.
- Gottlieb M, et al. Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome. Cochrane Database of Systematic Reviews. 2023.
- Aldridge S, Krishnan K. Using HINTS in acute vestibular syndrome: a practical guide for the acute care physician. 2025.
Medical disclaimer: This article is for education only and does not provide a diagnosis or emergency triage for an individual. HINTS is a clinician-performed examination and is not a home test. Seek urgent medical care for new or severe warning symptoms.
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