Back to Basics: Dizziness & the HINTS exam

HINTS Testing: series of three physical exam maneuvers to differentiate peripheral and central causes of vertigo

Head Impulse test: tests vestibulo-ocular reflex

• Patient focuses on visual spot directly in front of them

• Rotate patient’s head rapidly from center to 40 degrees to the left and back again to center, repeat on the right

Normal: eyes move smoothly in opposite direction of head (suggestive of CENTRAL vertigo)

Abnormal: patient cannot maintain eye contact with their visual stimulus > saccades to refocus on target (suggestive of PERIPHERAL vertigo)


• Observe patient looking straight ahead and looking laterally

Normal: unidirectional horizontal nystagmus (PERIPHERAL)

Abnormal: vertical nystagmus, eccentric nystagmus (when patient looks to the right, nystagmus is also to the right), or direction changing nystagmus (CENTRAL)

Test of Skew

• Have patient look directly ahead, cover one eye, then cover the other, and observe the response of the eye being uncovered

Normal: eyes remain motionless after being uncovered (PERIPHERAL)

Abnormal: after being uncovered, eyes will demonstrate saccade movements (CENTRAL)

In summary:

• Peripheral vertigo: ABNORMAL head impulse test, NORMAL nystagmus, NORMAL test of skew

• Central vertigo: NORMAL head impulse test, ABNORMAL nystagmus, ABNORMAL test of skew




Goldman B. Vertigo. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eNew York, NY: McGraw-Hill; 2016.

Newman-Toker DE, Kattah JC, Talkad AV, Wang DZ, Hsieh Y-H, Newman-Toker DE. H.I.N.T.S. to Diagnose Stroke in the Acute Vestibular Syndrome—Three-Step Bedside Oculomotor Exam More Sensitive than Early MRI DWI. Stroke; a journal of cerebral circulation. 2009;40(11):3504-3510. doi:10.1161/STROKEAHA.109.551234.


Johns, P., MD. (2016, July 12). Retrieved October 09, 2017, from Department of Emergency Medicine, University of Ottawa