Physical examination maneuver

Physical Exam

Head Impulse Test

also known as Head thrust test; Halmagyi test
🔒
Subscribe to view — from $5/moSign in to watchAlready a subscriber? Videos are for subscribers. Subscriptions are not available in the app.At a school or residency?

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

Showing all 4 findings

Stroke

HINTS exam concerning (central pattern) in a patient with acute vestibular syndrome
Rule in
Helpful
Rule out
Very helpful
Evidence:Strong
Head impulse test alone, normal
Rule in
Helpful
Rule out
Helpful
Evidence:Strong

Vestibular Dysfunction

HINTS exam reassuring (peripheral pattern) in a patient with acute vestibular syndrome
Rule in
Very helpfulDerived CI
Rule out
Very helpfulDerived CI
Evidence:Moderate
Head impulse test alone, abnormal
Rule in
Somewhat helpful
Rule out
Helpful
Evidence:Strong

Related Bedside Tests

Alternate Cover TestMembers
Sign in
Alternate Cover Test
aka Cross-cover test, Test of skew
Rule in:VHSkew Deviation, VHVestibular Dysfunction, HStroke +1 more
Rule out:VHStroke, VHVestibular Dysfunction, HSkew Deviation +1 more
Extraocular MovementsMembers
Sign in
Extraocular Movements
Rule in:VHStroke, SHHyperthyroidism, SHMyasthenia Gravis +9 more
Rule out:HMyasthenia Gravis, SHHyperthyroidism, NHOrbital Fracture +9 more
HINTS ExamMembers
Sign in
HINTS Exam
Rule in:VHVestibular Dysfunction, HStroke
Rule out:VHStroke, VHVestibular Dysfunction
Nystagmus CharacterizationMembers
Sign in
Nystagmus Characterization
Rule in:VHStroke, VHVestibular Dysfunction
Rule out:VHStroke, VHVestibular Dysfunction
Pupillary Light ReactionMembers
Sign in
Pupillary Light Reaction
Rule in:VHSerious Eye Disease, HPoor Neurologic Outcome, HStructural Brain Lesion +11 more
Rule out:SHPoor Neurologic Outcome, SHSerious Eye Disease, SHStructural Brain Lesion +11 more
🎬Video coming soon
Gait Assessment
Rule in:VHStroke, HFalls, HVascular Parkinsonism +24 more
Rule out:SHDementia, SHVascular Parkinsonism, MHFalls +24 more

Related Systems / Regions

Head, Eyes, Ears, Nose, ThroatNeurological

Related Diagnoses

StrokeVestibular Dysfunction

Related Chief Complaints

Balance ProblemsConfusionDifficulty SpeakingDifficulty WalkingDizzinessDouble VisionFacial DroopHeadacheNausea and VomitingNumbness on One SideSlurred SpeechSpinning SensationSudden Vision LossUnsteady GaitVertigoVision ChangesWeakness on One Side

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.
  • Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013;20(10):986-996. doi:10.1111/acem.12223. PMID: 24127701.
  • 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.
  • Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol. 1988;45(7):737-739.

Research last updated September 9, 2026.