EBM Consult

The HINTS Exam for Bedside Diagnosis of Central Causes of Dizziness


  • P = Patients presenting with acute vestibular syndrome
  • I  = HINTS examination
  • C = Evaluation with MRI
  • O = Diagnosis of central etiologies of vestibular syndrome
  • T = Acute Setting (within 1 hour to 2 weeks) 
  • S = Emergency Department

: PICOTS stands for (P) for patient, (I) for intervention of interest, (C) for comparison, (O) for outcome of interest, (T) for timing, & (S) for setting.

Take Home Point(s)

  • The HINTS (Head Impulse, Nystagmus and Test of Skew) exam should only be performed on patients with acute spontaneous vestibular syndrome. These include patients with ongoing continuous symptoms of vertigo/dizziness, gait unsteadiness, nausea or vomiting.
  • The data supporting the HINTS exam is based on the examination being performed by a specialist or sub-specialist.
  • A dangerous HINTS exam is more sensitive than MRI with DWI within the first 48 hours. Therefore, a dangerous HINTS exam should carry a  high clinical suspicion for central etiologies even in the setting of a negative MRI within the first 2 days.


Acute Vestibular Syndrome is defined as continuous and unprovoked symptoms of dizziness or vertigo, nystagmus, gait unsteadiness nausea or vomiting.  These patients often present as a diagnostic dilemma in the diagnosis of peripheral vs. central causes of these symptoms. The HINTS (Head impulse, Nystagmus and Test of Skew) exam is a neurologic exam developed to diagnose or exclude central etiologies of vertigo or dizziness in these patients. It has been found to be both sensitive and specific in the diagnosis of central vertigo when performed by a trained professional in the correct patient population, and can even outperform MRI within the first 48 hours. In much of the available literature the exam is performed by a trained professional such as a neurologist, neuro-otologist or neuro-ophthalmologists. Unfortunately, there is only limited data on the generalizability of these results to other providers such as general or emergency physicians trained in the exam.

Author(s):  Aaryn K. Hammond, MD - (Johns Hopkins School of Medicine)

Editor(s): Jeremiah Hinson, MD, PhD - (Johns Hopkins School of Medicine) and Dylan Kellogg, MD - (Arnot Ogden Medical Center)

Editor-in-Chief:  Anthony J. Busti, MD, PharmD, FNLA, FAHA 

Date Last Reviewed:  May 2018

Guideline Statements

  • 2017 American Academy of Otolaryngology: Head and Neck Surgery
    Benign Paroxysmal Positional Vertigo Clinical Practice Guidelines:
    "Statement 2a: Differential Diagnosis: Clinicians should differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo. Recommendation based on observational studies and a preponderance of benefit over harm."

    "Statement 3b. Vestibular Testing: Clinicians should not order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing.  Recommendation against vestibular testing based on diagnostic studies with limitations and a preponderance of benefit over harm."

    • Note:  The following comment is also available on page S19, "Comprehensive vestibular testing is unnecessary for patients who already meet clinical criteria for the diagnosis of BPPV (Table 6). This does not imply that the use of video-oculographic technology with or without recording should not be used when available to help in identification and differentiation of types of BPPV."
  • 2014 American Heart Association / American Stroke Association
    Guidelines for Management of Cerebral and Cerebellar Infarction with Swelling:

    There is no mention of the HINTS exam or vestibular testing to different if the dizziness is central in origin or if a cause of stroke.

  • 2013 American Heart Association / American Stroke Association
    Guidelines for the Early Management of Patients with Acute Ischemic Stroke:

    There is no mention of the HINTS exam or vestibular testing to different if the dizziness is central in origin or is a cause of stroke.

Cochrane Review

  • No known publications available.

Systematic Review / Meta-Analysis

  • No known publications available.

Original Studies

  • Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009;40:3504-10. PubMed

  • Kerber KA, Meurer WJ, Brown DL, et al. Stroke risk stratification in acute dizziness presentations: A prospective imaging-based study. Neurology 2015;85:1869-78.  PubMed

  • Vanni S, Nazerian P, Casati C, et al. Can emergency physicians accurately and reliably assess acute vertigo in the emergency department? Emerg Med Australas 2015;27:126-31.  PubMed

Supporting Studies

  • Kerber KA, Morgenstern LB, Meurer WJ, et al. Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support? Acad Emerg Med 2011;18:619-26.  PubMed

  • Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013;20:986-96.  PubMed

Review Articles

  • Newman-Toker DE. Symptoms and signs of neuro-otologic disorders. Continuum (Minneap Minn) 2012;18:1016-40.  PubMed

  • Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin 2015;33:577,99, viii.  PubMed

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