Physical examination maneuver

Physical Exam

HINTS Exam

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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

Showing all 2 findings

Stroke

HINTS exam concerning (central pattern) in a patient with acute vestibular syndrome
Rule in
Helpful
Rule out
Very 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

Related Bedside Tests

Alternate Cover TestMembers
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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
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Extraocular Movements
Rule in:VHStroke, SHHyperthyroidism, SHMyasthenia Gravis +9 more
Rule out:HMyasthenia Gravis, SHHyperthyroidism, NHOrbital Fracture +9 more
Head Impulse TestMembers
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Head Impulse Test
aka Head thrust test; Halmagyi test
Rule in:VHVestibular Dysfunction, HStroke
Rule out:VHStroke, VHVestibular Dysfunction
Nystagmus CharacterizationMembers
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Nystagmus Characterization
Rule in:VHStroke, VHVestibular Dysfunction
Rule out:VHStroke, VHVestibular Dysfunction
Pupillary Light ReactionMembers
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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
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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

  • 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.
  • 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.