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 slowly turn it 10–20° to one side. At an unpredictable moment, rapidly bring the head back to center while closely watching the eyes. Repeat several times, then test the other side. Normally, the eyes remain fixed on your nose throughout each impulse. If the patient’s gaze briefly moves with the head past your nose and then quickly jumps back to refixate on it, this is a corrective saccade and an abnormal test.

How to Interpret

Stroke

Posterior Circulation Stroke

HINTS exam concerning (central pattern) in a patient with acute vestibular syndrome

Rule in

HelpfulDerived CI

Rule out

Very helpfulDerived CI

Evidence:Strong

Head impulse test alone, normal

Rule in

Helpful

Rule out

Helpful

Evidence:Strong

Vestibular Dysfunction

Peripheral Vestibular Dysfunction

HINTS exam reassuring (peripheral pattern) in a patient with acute vestibular syndrome

Rule in

Very helpfulDerived CI

Rule out

HelpfulDerived CI

Evidence:Strong

Head impulse test alone, abnormal

Rule in

Somewhat 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.
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. PMCID PMC10620998.
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.
Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol. 1988;45(7):737-739.

Research last updated September 9, 2026.