For clinician education only. This is a static reference for the correct clinical context, components, documentation, and limits of HINTS/HINTS+ and the ABCD2 score. It is not a patient self-check, diagnostic calculator, training course, substitute for supervised training, or substitute for local emergency and stroke protocols.

No answer buttons, score calculator, low-risk label, automated output, or clinic-delay pathway appears on this page.

HINTS is an examination, not a score

HINTS means Head-Impulse, Nystagmus, Test-of-Skew. It is a structured bedside eye-movement examination, not a numerical score and not a stand-alone diagnosis.

Before documenting HINTS, record why it is clinically applicable. The intended setting is a clinician-assessed acute vestibular syndrome: acute, persistent dizziness or vertigo with a compatible examination. The timing-and-trigger pattern, spontaneous-nystagmus status, gait or truncal stability, full neurological examination, hearing symptoms, vascular risk, and examiner training context must all be recorded.

HINTS is not a routine test for brief, clearly positional episodes, presyncope, a vague chronic dizziness complaint, or online self-screening. If the clinician is not trained to perform and interpret it, the record should say so; a HINTS interpretation must not be manufactured from a partial examination.

The SAEM GRACE-3 guideline recommends that trained clinicians use HINTS in patients with nystagmus in the appropriate acute-dizziness setting. In patients without nystagmus, it recommends assessing gait unsteadiness rather than assigning a HINTS result.

HINTS: the three components

1. H — Head impulse

Clinical item: vestibulo-ocular reflex observation in the horizontal plane.

Record: whether the observation is normal or abnormal, the side if relevant, whether it was interpretable, and the rest of the examination context.

Central-concerning pattern in the appropriate setting: a normal horizontal head-impulse result.

Important limit: an abnormal head impulse is not a stand-alone exclusion of stroke or other central disease. It must never be used alone to reassure a patient or close an emergency assessment.

2. N — Nystagmus

Clinical item: spontaneous and gaze-related nystagmus.

Record: whether nystagmus is present, direction, gaze dependence, and whether the observation was interpretable.

Central-concerning patterns in the appropriate setting: direction-changing gaze-evoked nystagmus, or vertical/torsional nystagmus.

Important limit: the absence of an interpretable nystagmus pattern does not create a “normal HINTS.” It changes whether HINTS is the appropriate framework and should prompt assessment and escalation under the local pathway as clinically indicated.

3. TS — Test of skew

Clinical item: vertical ocular alignment.

Record: whether skew deviation is seen, whether the observation was interpretable, and the associated neurological findings.

Central-concerning pattern in the appropriate setting: skew deviation.

Important limit: a negative or uninterpretable skew observation cannot by itself exclude a central cause.

Reading the HINTS pattern safely

In the correct acute-vestibular-syndrome setting and only when assessed by a trained clinician, a central-concerning or equivocal HINTS pattern requires emergency escalation under the local stroke pathway. The treating team decides whether emergency neurology review, MRI/MRA, vascular imaging, or other testing is required.

A peripheral-compatible pattern is an interpretation of the complete examination, not a patient clearance, a guarantee against stroke, or a universal replacement for imaging. No statement on this page compares HINTS universally with MRI, CT, or any other test.

For background on the clinical framework, see the site’s general HINTS examination guide and central and concerning HINTS findings guide.

HINTS+: the additional hearing assessment

HINTS+ adds a bedside hearing assessment in the appropriate setting. The documentation should state the bedside method used, side, onset and timing of any hearing change, whether it is new or unilateral, and the plan for corroborating assessment where required.

New sudden hearing loss in one ear needs same-day urgent medical or ENT assessment. It must not be redirected to a routine appointment or used to reassure a patient with acute dizziness.

ABCD2: complete seven-point score

What ABCD2 is—and is not

ABCD2 was developed to estimate short-term stroke risk after a suspected transient ischaemic attack (TIA). It is not a diagnosis of TIA, a HINTS substitute, a posterior-circulation-stroke rule-out tool, or a self-calculator for a person with dizziness.

For acute dizziness or vertigo, it must not replace the timing-and-trigger assessment, full neurological examination, gait assessment, hearing assessment, HINTS where appropriate and performed by a trained clinician, or the local stroke pathway.

Point-by-point ABCD2 table

Domain Required clinical data Points
A — Age Age 60 years or older 1
B — Blood pressure Initial blood pressure: systolic 140 mm Hg or higher, or diastolic 90 mm Hg or higher 1
C — Clinical features Unilateral weakness 2
Speech impairment without unilateral weakness 1
D — Duration Symptoms lasting 60 minutes or longer 2
Symptoms lasting 10 to 59 minutes 1
D — Diabetes Diabetes mellitus present 1

Maximum score: 7. Each domain should be documented from the clinical history and examination. Record the components, onset/timing, neurological findings, and clinical reasoning—not only the total.

ABCD2 documentation boundaries

  • Do not expose a patient-facing calculator or publish automatic score bands on this page.
  • Do not describe a low total as safe, benign, or suitable for delayed assessment.
  • Do not use the total to rule out posterior-circulation stroke, acute vestibular syndrome, or another emergency diagnosis.
  • If ABCD2 is clinically relevant to suspected TIA, retain the component data and record the local pathway or consultation decision.
  • A score is only one item in clinical judgement; it cannot replace the presentation pattern, examination, investigations, or safety-netting.

Minimum clinician documentation template

Presentation pattern, onset, duration, and triggers:
Emergency neurological, cardiac, or hearing symptoms:
Spontaneous nystagmus present: yes / no / uncertain
Gait or truncal stability:
HINTS applicability and examiner training context:
Head-impulse observation and interpretability:
Nystagmus observation, direction, gaze dependence, and interpretability:
Test-of-skew observation and interpretability:
HINTS+ hearing observation, method, side, and onset, if performed:
Full neurological examination and relevant vascular risk:
ABCD2 component data, if clinically relevant:
Imaging, consultation, escalation, and local pathway decision:
Safety-netting, transport advice, and handover:

Essential limitations and escalation boundary

  • HINTS/HINTS+ requires appropriate clinical context and clinician training.
  • A central-concerning or equivocal result requires emergency escalation under local pathways.
  • A peripheral-compatible pattern does not grant patient clearance or exclude central disease by itself.
  • Full neurological examination, gait/truncal assessment, history, vascular risk, and hearing assessment remain essential.
  • CT, MRI, and vascular-imaging choices belong to the treating team and local pathway; this reference makes no universal imaging comparison.
  • No part of this page is a procedure-training guide, a patient self-test, a remote diagnosis service, or an alternative to emergency care.

References

  1. Society for Academic Emergency Medicine — GRACE-3: Acute Dizziness and Vertigo
  2. Cochrane review — HINTS/HINTS+ for central causes of acute vestibular syndrome
  3. Critical review — HINTS+, STANDING, and risk scores
  4. ABCD2 component definitions
  5. Prospective ABCD2 validation in emergency-department TIA patients

Medical Disclaimer: This article is for educational purposes only and does not constitute medical advice, diagnosis or prescribing guidance. Consult Dr. Prateek Porwal at Prime ENT Center, Hardoi for personalised treatment.