New review article shows HINTS test often used on the wrong patients
The HINTS examination can help physicians distinguish between stroke and vestibular neuritis in patients with acute persistent dizziness. However, the test is often used in situations for which it was not intended, which may lead to both missed stroke diagnoses and unnecessary investigations. This is shown in a review article from Karolinska Institutet published in the journal JAMA Neurology.
Acute persistent dizziness is a common reason for seeking care in the emergency department. One of the methods used to assess patients with acute dizziness is HINTS (Head Impulse, Nystagmus, Test of Skew). It is a simple bedside examination of eye movements that was introduced more than 15 years ago to distinguish between vestibular neuritis, a disorder of the peripheral vestibular system, from stroke affecting the cerebellum or brainstem.
In the new review article, the researchers compiled and analysed previous studies on HINTS, acute vestibular syndrome and the diagnosis of stroke in patients presenting with acute dizziness. They also compared how acute vestibular syndrome is defined across scientific publications, clinical guidelines and established educational resources.
The review shows that HINTS is reliable only in patients with acute persistent dizziness together with nystagmus, or involuntary eye movements, at rest.
“HINTS can be a valuable tool when used in the appropriate patient group. At the same time, our review shows that the test is often used in patients for whom the necessary conditions for interpreting the results are not present”, says Carl Sars, MD, doctoral student at the Breast surgery group, the Department of Molecular Medicine and Surgery, Karolinska Institutet, and first author of the article.
”We also emphasize that clinicians should first look for other neurological warning signs of stroke, such as double vision, speech or swallowing difficulties, impaired coordination, or marked gait disturbance, before applying the HINTS examination”.
Despite this, previous studies show that HINTS is frequently performed in patients without nystagmus. In two emergency department studies, HINTS was used inappropriately in patients without nystagmus in 71–97 per cent of reviewed cases.
”The main message is that HINTS is not a general test for every patient presenting with acute dizziness. It can be a powerful diagnostic tool when applied to the correct patient population, but it may be misleading when used in the wrong clinical setting. Misapplication can have consequences in both directions: a stroke may be missed, while patients with benign causes of dizziness may undergo unnecessary investigations such as CT or MRI,” says Carl Sars.
One potential application is therefore the development of clearer clinical algorithms and educational resources for emergency physicians and other clinicians who assess patients with acute dizziness. We propose a stepwise approach in which clinicians first screen for neurological warning signs, then determine whether nystagmus at rest is present, and only then use HINTS in the appropriate patient group. In patients without nystagmus, objective assessment of gait becomes particularly important
The review has been conducted together with researchers from Canada and last author is Peter Johns, University of Ottawa.
Publication
When to Use the HINTS Examination in Patients With Dizziness, Sars C, Lelli D, Tse D, Johns P, JAMA Neurol
Published Online: September 21, 2026 doi: 10.1001/jamaneurol.2026.2942