Physical Exam

HINTS Exam

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Video coming September 2026

How to Perform

Perform three bedside steps in a patient who has continuous spontaneous nystagmus. First, the head impulse test: with the patient fixating on your nose, slowly turn the head 10–20° to one side, then abruptly bring it back to center while watching for a corrective catch-up saccade; repeat on the other side. Second, observe the nystagmus with the eyes in primary position and in gaze to each side, noting the direction of the fast phase and whether it stays the same or changes with gaze direction. Third, the test of skew: perform an alternating cover test, covering and uncovering each eye in turn, and watch for a vertical corrective movement of the eye as it is uncovered.

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

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

References

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.
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(11):3504-3510.

Research last updated September 9, 2026.