When to Use the HINTS Examination in Patients With Dizziness: A Review

The Head Impulse, Nystagmus, Test of Skew (HINTS) examination is a widely recognized bedside tool for distinguishing peripheral vestibular disorders from central causes, such as stroke, in patients presenting with acute vestibular syndrome. However, despite its introduction in 2009, confusion persists regarding its proper application. Misuse of the HINTS examination, particularly when applied to inappropriate patient populations, may lead to misdiagnosis, unnecessary imaging, or missed strokes. This review aims to clarify the appropriate use of the HINTS examination and to address misconceptions that contribute to diagnostic errors in emergency and clinical practice.

HINTS is most effective when performed for patients with continuous dizziness and spontaneous nystagmus at rest. However, various guidelines and educational resources have failed to clearly define these criteria, leading to widespread misapplication of the test. Common errors include using HINTS for patients without nystagmus, failing to screen for central features before performing the examination, and misinterpreting test components. Studies show that the HINTS examination, when applied correctly, has high sensitivity for detecting stroke, but its diagnostic accuracy declines significantly when used for inappropriate patients. Furthermore, recent guidelines, such as the third Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-3), may have introduced ambiguities that may contribute to ongoing confusion in clinical practice.

To optimize the diagnostic utility of the HINTS examination and reduce stroke misdiagnosis, clinicians should first screen for central features before applying HINTS and ensure it is only performed for patients with nystagmus at rest. Future guidelines should provide clearer recommendations to prevent inappropriate HINTS use and thus avoid inaccurate results. Emphasizing the correct application of HINTS in the right patient population will enhance its reliability as a critical tool for emergency physicians in distinguishing central from peripheral causes of dizziness, ultimately improving patient outcomes and reducing unnecessary investigations.