What is the best approach to diagnose and manage a patient presenting with vertigo, including the use of the HINTS (Head Impulse test, Nystagmus, and Test of Skew) exam and the Dix-Hallpike maneuver?

Diagnostic Approach to Vertigo: HINTS Exam and Dix-Hallpike Maneuver

The Dix-Hallpike maneuver is the gold standard for diagnosing benign paroxysmal positional vertigo (BPPV), while the HINTS examination is a three-part bedside test that distinguishes central from peripheral causes in patients with acute vestibular syndrome—but HINTS is only reliable when performed by trained specialists, not general emergency physicians. 1, 2, 3

The Dix-Hallpike Maneuver: Technique and Interpretation

How to Perform the Maneuver

Position the patient seated upright on an examination table with enough space for the head to hang 20 degrees below the table edge when supine. 4

The step-by-step technique:

• Rotate the patient's head 45 degrees to the right to align the right posterior semicircular canal with the sagittal plane 4
• Rapidly move the patient from seated to supine while maintaining the 45-degree head rotation 4
• Extend the neck 20 degrees so the head hangs off the table edge with the chin pointed slightly upward 4
• Observe for nystagmus and ask about vertigo symptoms for up to 60 seconds 4
• Repeat the entire maneuver on the opposite side to test the left ear 4

Positive Test Criteria for BPPV

A positive Dix-Hallpike demonstrates three essential features: 4, 1

• Latency period of 5-20 seconds (rarely up to 60 seconds) between completing the maneuver and onset of symptoms 4
• Torsional, upbeating nystagmus with the fast component beating toward the affected (downward) ear 4, 1
• Symptoms that crescendo then resolve within 60 seconds from nystagmus onset 4

Clinical Pearls and Contraindications

Warn patients before starting that they will experience intense vertigo and nausea, which will subside within one minute. 4

Avoid the Dix-Hallpike maneuver in patients with: 4

• Cervical stenosis or severe kyphoscoliosis
• Limited cervical range of motion
• Severe rheumatoid arthritis or ankylosing spondylitis
• Known cerebrovascular disease
• Morbid obesity

Critical pitfall: Up to one-third of patients with atypical histories will still have positive Dix-Hallpike testing, so perform the maneuver even when the history is unclear. 4

The HINTS Examination: When and How to Use It

Appropriate Clinical Context

The HINTS exam applies ONLY to patients with acute vestibular syndrome (AVS)—continuous vertigo lasting days, with nystagmus, head motion intolerance, nausea/vomiting, and gait unsteadiness. 1, 2, 3

Do NOT use HINTS for: 1, 5

• Brief episodic vertigo triggered by position changes (use Dix-Hallpike instead)
• Intermittent dizziness without continuous symptoms
• Patients without spontaneous nystagmus

The Three Components of HINTS

1. Head Impulse Test (HIT):

• Rapidly rotate the patient's head 10-20 degrees to one side while they fixate on your nose 1, 2
• Normal (abnormal HIT) = peripheral cause: Eyes stay fixed on target 1
• Abnormal (normal HIT) = central cause: Eyes remain fixed without corrective saccade, suggesting intact vestibulo-ocular reflex 1, 2

2. Nystagmus Assessment:

• Observe spontaneous nystagmus in primary gaze and with lateral gaze 1, 2
• Unidirectional horizontal nystagmus = peripheral cause 1
• Direction-changing, vertical, or gaze-evoked nystagmus = central cause 1, 2

3. Test of Skew (Vertical Ocular Misalignment):

• Perform alternate cover test looking for vertical eye deviation 1, 2
• Absent skew deviation = peripheral cause 1
• Present skew deviation = central cause 1, 2

HINTS Plus: Adding Hearing Assessment

HINTS Plus adds acute unilateral hearing loss assessment, which when present with otherwise peripheral HINTS findings, suggests anterior inferior cerebellar artery stroke. 1, 2

Diagnostic Accuracy: The Critical Training Gap

Performance by Trained Specialists

When performed by neurologists with specialized training (neuro-otology or neuro-ophthalmology), HINTS has 96.7% sensitivity and 94.8% specificity for detecting central causes, outperforming early MRI (100% vs 46% sensitivity). 1, 2, 3

HINTS Plus performed by trained specialists has 95.3% sensitivity and 72.9% specificity. 2

Performance by Emergency Physicians

The critical limitation: When performed by emergency physicians without specialized training, HINTS sensitivity drops to 83% and specificity plummets to 44%—making it unreliable for ruling out stroke. 6, 3

In one retrospective study of 450 ED patients receiving HINTS, 96.9% did not meet criteria for the exam (lacking continuous symptoms or nystagmus), and the test failed to identify any central causes. 6

Algorithmic Approach to Vertigo Evaluation

Step 1: Classify by Timing and Triggers

Focus on duration and triggers, NOT the patient's description of "spinning" versus "lightheadedness": 4, 1

• Seconds to <1 minute, triggered by position changes → Perform Dix-Hallpike for BPPV 1
• Minutes to hours, spontaneous episodes → Consider Ménière's disease or vestibular migraine 1
• Days of continuous symptoms → Acute vestibular syndrome requiring HINTS or imaging 1
• Weeks to months → Consider medication effects, anxiety, or posterior fossa mass 1

Step 2: Identify Red Flags Requiring Urgent Imaging

Obtain MRI brain without contrast immediately for: 4, 1, 7

• Focal neurological deficits beyond vertigo
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or other central nystagmus patterns
• New severe headache with vertigo
• Age >50 with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)
• Positive Romberg test or neck stiffness

Step 3: Apply Appropriate Diagnostic Test

For brief episodic positional vertigo:

• Perform bilateral Dix-Hallpike maneuver 4, 1
• If positive with typical findings: Diagnose BPPV, perform Epley maneuver, no imaging needed 4, 1
• If negative or atypical nystagmus: Consider imaging for central causes 4

For acute vestibular syndrome without red flags:

• If trained HINTS examiner available: Perform HINTS examination 1, 2
• If HINTS shows peripheral pattern AND examiner is trained: No imaging needed, diagnose vestibular neuritis 4, 1
• If no trained HINTS examiner OR high vascular risk: Obtain MRI brain without contrast 4, 1

Common Diagnostic Pitfalls to Avoid

Do not assume a normal neurological examination excludes stroke—75-80% of posterior circulation strokes causing acute vestibular syndrome have no focal neurologic deficits initially. 1, 7

Do not perform Dix-Hallpike when Romberg is positive or neck stiffness is present, as these indicate central pathology requiring imaging first. 1, 7

Do not use HINTS examination if you lack specialized training in neuro-otology or neuro-ophthalmology—the false negative rate is unacceptably high. 6, 3

Do not order CT head for suspected posterior circulation stroke—it misses most posterior circulation infarcts with only 20-40% sensitivity compared to MRI's superior detection. 4, 8

Do not use HINTS for patients with intermittent symptoms or those lacking spontaneous nystagmus—the exam only applies to continuous acute vestibular syndrome. 6, 5

Do not perform both Dix-Hallpike and HINTS on the same patient—these tests are for mutually exclusive populations (episodic triggered vertigo versus continuous acute vestibular syndrome). 6, 5