This review examines the proper indications and common misapplications of the HINTS examination (Head Impulse, Nystagmus, Test of Skew) for distinguishing peripheral vestibular disorders from central causes (e.g., stroke) in patients presenting with acute vestibular syndrome.
HINTS has high sensitivity for stroke detection when applied correctly — specifically to patients with continuous dizziness and spontaneous nystagmus at rest — but diagnostic accuracy declines significantly when used in patients without nystagmus or without prior screening for central features.
This is a narrative review without a systematic search or meta-analysis, so effect size estimates for misapplication are not quantified. The critique of GRACE-3 guidelines reflects the authors' interpretation rather than empirical data.
Before performing HINTS, first screen for central features and confirm the patient has spontaneous nystagmus at rest — if there is no nystagmus, do not use HINTS. Reserving HINTS for the correct population (acute vestibular syndrome with continuous dizziness and resting nystagmus) is essential to avoid missed strokes or unnecessary imaging.
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