HINTS Testing After Vertigo Resolution
No, the HINTS examination should not be performed once vertigo has resolved, as it is specifically designed and validated only for patients with acute, persistent, ongoing vertigo as part of Acute Vestibular Syndrome (AVS). 1
Why HINTS Requires Active Symptoms
The HINTS examination is exclusively indicated for patients presenting with Acute Vestibular Syndrome, which requires all of the following active symptoms 1:
- Acute, persistent (not intermittent) vertigo
- Nausea and/or vomiting
- Head motion intolerance
- Ongoing nystagmus (visible involuntary eye movements)
- Gait unsteadiness
Without active nystagmus and persistent vertigo, the HINTS examination cannot be properly performed or interpreted. 1 The head impulse test assesses the vestibulo-ocular reflex during active vestibular dysfunction, the nystagmus assessment requires visible eye movements to evaluate direction and characteristics, and the test of skew evaluates vertical misalignment that may only be present during acute symptoms. 1
Critical Patient Selection Error
A major pitfall identified in clinical practice is performing HINTS on patients who don't meet criteria. One retrospective study found that 96.9% of patients who received HINTS testing in the emergency department did not actually meet criteria for the examination, most commonly because they lacked documented nystagmus or described intermittent rather than persistent symptoms. 2 This misapplication of the test contributed to its poor diagnostic performance in routine emergency department settings. 2
What to Do Instead for Resolved Vertigo
If vertigo has already resolved by the time of evaluation:
Consider the temporal pattern: Resolved symptoms suggest either a self-limited peripheral cause (like vestibular neuritis) or episodic conditions (like BPPV or transient ischemic attack) rather than ongoing AVS 3
For episodic positional symptoms: Perform the Dix-Hallpike test to diagnose posterior canal BPPV, which is appropriate for triggered episodic vestibular syndrome 3
For spontaneous episodic symptoms: Search for symptoms or signs of cerebral ischemia and consider vascular imaging (CT angiography or MRI angiography) if concerned about transient ischemic attack, particularly in patients over 50 with vascular risk factors 1, 3
Risk stratification remains important: Even with resolved symptoms, patients over 50 years with vascular risk factors (hypertension, diabetes, smoking, atrial fibrillation), focal neurologic deficits, or new severe headache/neck pain require imaging regardless of examination findings 1
The Timing Window
HINTS must be performed while the patient is actively symptomatic with continuous vertigo and visible nystagmus. 1 Once symptoms resolve, the window for this bedside examination has closed, and clinical decision-making must rely on history, risk factors, and potentially imaging rather than the HINTS examination itself.