Physical Exam

Head Impulse Test

also known as Head thrust test; Halmagyi test

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Video coming September 2026

How to Perform

Ask the patient to keep their eyes fixed on your nose. Hold the patient's head with both hands and turn it a small amount (about 10–20°) to one side at a high, abrupt velocity, with the timing unpredictable; then repeat to the other side. Watch the eyes during and immediately after each turn. A positive (abnormal) test is a visible corrective catch-up saccade — the eyes are dragged off the target by the head turn and then flick back to refixate; a normal response keeps the eyes locked on your nose throughout.

How to Interpret

Peripheral Vestibular Dysfunction

Abnormal head impulse test

Rule in

Somewhat helpful

Rule out

Helpful

Evidence:Strong

Posterior Circulation Stroke

Normal head impulse test

Rule in

Helpful

Rule out

Helpful

Evidence:Strong

References

Ooi S, Phillips G, Tang T, Chen L, Fok A, Ly J, Ma H, Phan TG. Meta-Analysis of the Use of Head Impulse Test and Head Impulse Test with Direction Changing Nystagmus and Test of Skew Deviation in the Diagnosis of Peripheral Vertigo and Stroke. Cerebrovasc Dis. 2023;52(2):184-193. doi:10.1159/000526331. PMID 36088909. Bivariate-method meta-analysis; HIT pooled across 8 studies (N=417); advanced-imaging or neurologist-diagnosis reference standard; acute vestibular syndrome.
Gottlieb M, Peksa GD, Carlson JN. Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome. Cochrane Database Syst Rev. 2023 Nov 2;11(11):CD015089. doi:10.1002/14651858.CD015089.pub2. PMID 37916744. PMC10620998. Cochrane diagnostic-test-accuracy review; bivariate pooling; composite estimate from the 8-study advanced-imaging-reference subgroup (n=1146).
Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol. 1988;45(7):737-739.