HINTS belongs to one patient: continuous dizziness with nystagmus at rest

A review in JAMA Neurology (21 September) addresses a decade of confusion about the HINTS examination (Head Impulse, Nystagmus, Test of Skew). The authors argue that it was validated, and is highly sensitive for stroke, only in acute vestibular syndrome — continuous dizziness with spontaneous nystagmus at rest.

The commonest errors are using it in patients without nystagmus, skipping a screen for central features such as ataxia, dysarthria or inability to stand before doing it, and misreading its components. Used outside its population, its accuracy falls sharply and it can both miss strokes and prompt unnecessary imaging. The authors also suggest that the GRACE-3 emergency guideline may have added ambiguity about when to apply it.

This is a narrative review rather than new data, but it describes a real and common error. In a patient with episodic or positional dizziness and no nystagmus at rest, HINTS does not apply at all; the right tests are different, such as the Dix–Hallpike.

• First screen for central signs: gait and truncal ataxia, dysarthria, limb ataxia, other cranial nerve signs
• Only then, and only if there is spontaneous nystagmus at rest, perform HINTS
• No spontaneous nystagmus: do not use HINTS; consider positional testing instead
• If HINTS is not applicable or equivocal, image with MRI including diffusion — early CT misses posterior strokes
• Teach this sequence to emergency and medical trainees who see dizziness first

Why it matters

HINTS applied to the wrong patient is a documented route to missed posterior circulation stroke.

Don't overread it

This is a narrative review — it clarifies existing evidence rather than adding new accuracy data.

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