Introduction

Dizziness and vertigo are among the most common neurological complaints seen in clinical practice. While many cases are caused by peripheral vestibular disorders, a small but critical percentage are due to posterior circulation stroke.

Distinguishing between these causes can be difficult based on symptoms alone. This is where the HINTS+ exam becomes an invaluable bedside assessment tool.

Used appropriately in patients with acute vestibular syndrome (AVS), the HINTS Plus exam helps clinicians differentiate between peripheral vestibular disorders and potentially life-threatening central causes such as stroke.

In this article, we’ll explore the clinical purpose of the HINTS+ exam and why it has become such an important skill for clinicians assessing dizziness.

For a full clinical breakdown and demonstration of the exam, see the course: HINTS+ Exam Demystified: Differentiating Central vs. Peripheral Causes of Acute Dizziness.

What Is Acute Vestibular Syndrome?

The HINTS+ exam is specifically used for patients with Acute Vestibular Syndrome (AVS).

AVS refers to the sudden onset of continuous dizziness or vertigo lasting hours to days, often accompanied by:

• Spontaneous nystagmus

• Nausea and vomiting

• Intolerance to head movement

• Postural instability or gait disturbance

Two of the most common causes of AVS include:

1) Peripheral causes: Acute unilateral vestibulopathy (commonly called vestibular neuritis)

2) Central causes: Posterior circulation stroke involving the cerebellum or brainstem

Because symptoms often overlap, differentiating these conditions can be challenging without careful clinical examination.

Why the HINTS+ Exam Matters

Posterior circulation strokes account for roughly 20% of all strokes, and dizziness is often the presenting symptom.

However, diagnosing these strokes can be difficult. Early MRI imaging may miss small posterior strokes in the first 24–48 hours, creating a diagnostic gap during the critical early stage.

The HINTS+ exam was developed to help bridge this gap by using targeted bedside eye movement testing to identify patterns that suggest either peripheral or central pathology.

When performed correctly in the appropriate patient population, research suggests the HINTS+ exam can be highly sensitive for detecting stroke in acute vestibular syndrome.

Because of this, it has become an increasingly important tool for clinicians involved in dizziness assessment.

What Does “HINTS+” Stand For?

The HINTS+ exam is a series of bedside assessments evaluating ocular motor and vestibular function.

It includes four key components:

1. Head Impulse Test
   Assesses the vestibulo-ocular reflex and helps identify peripheral vestibular hypofunction.
   
   
2. Nystagmus Assessment
   Examines the characteristics and direction of spontaneous eye movements.
   
   
3. Test of Skew
   Looks for vertical ocular misalignment that may indicate central pathology.
   
   
4. Hearing Assessment (the “Plus”)
   Screens for new unilateral hearing loss, which can sometimes occur with certain types of stroke.

Interpreting the pattern of these findings together helps clinicians determine whether symptoms are more consistent with a peripheral vestibular disorder or a central neurological cause.

Why Many Clinicians Struggle With Dizziness Assessment

Despite how common dizziness is in clinical practice, many clinicians receive limited formal training in vestibular examination techniques.

Common challenges include:

• Difficulty interpreting nystagmus patterns

• Uncertainty performing the head impulse test correctly

• Recognizing subtle central signs

• Distinguishing stroke from benign vestibular disorders

Without proper training, these assessments can feel intimidating or unreliable.

Learning the HINTS+ exam requires understanding vestibular physiology, recognizing abnormal eye movements, and applying clinical reasoning in real time.

Learning to Perform the HINTS+ Exam Correctly

While the HINTS+ exam is conceptually straightforward, performing it accurately requires practice and proper instruction.

Small errors in technique or interpretation can significantly affect diagnostic accuracy.

In the course, HINTS+ Exam Demystified: Differentiating Central vs. Peripheral Causes of Acute Dizziness, clinician and educator Kregg Ochitwa walks through:

• How to perform each component of the HINTS exam

• Common pitfalls clinicians encounter

• How to interpret findings clinically

• When the test should (and should not) be used

• How to apply the exam safely in real patients

The course focuses on practical clinical reasoning and real-world application, making it easier to incorporate the HINTS+ exam into everyday dizziness assessments.

When the HINTS+ Exam Should Be Used

An important principle of the HINTS+ exam is that it is only validated for a specific patient presentation.

It should be used in patients with acute vestibular syndrome, which typically includes:

• Continuous vertigo or dizziness

• Spontaneous nystagmus

• Symptoms lasting hours to days

• Intolerance to head motion

It is not appropriate for episodic dizziness, positional vertigo, or non-vestibular dizziness.

Understanding when to apply the test is just as important as knowing how to perform it.

Improving Clinical Confidence With Dizziness Patients

For many clinicians, dizziness cases can feel unpredictable and high-risk. Missing a stroke can have serious consequences, while over-referral can create unnecessary anxiety and resource use.

Developing a structured assessment approach, including tools like the HINTS+ exam, can significantly improve confidence and decision-making.

With proper training, clinicians can:

• Recognize dangerous central signs earlier

• Better differentiate stroke from peripheral vestibular disorders

• Communicate findings clearly to other healthcare providers

• Improve patient safety and outcomes

Learn the HINTS+ Exam Step-by-Step

If you want to learn how to perform and interpret the HINTS+ exam confidently, the full training is available in this Embodia online course.

In this course, Kregg Ochitwa, BScPT, CWCE, CredMDT, demystifies the exam and explains how clinicians can integrate it into real-world dizziness assessments.

You’ll gain a deeper understanding of:

• Vestibular physiology

• Eye movement interpretation

• Clinical reasoning for acute dizziness

• Safe identification of potential stroke presentations

Frequently Asked Questions

What is the HINTS+ exam?

The HINTS+ exam is a series of bedside eye movement and hearing tests used to differentiate central causes of dizziness (such as stroke) from peripheral vestibular disorders in patients with acute vestibular syndrome.

Is the HINTS+ exam reliable?

When performed by trained clinicians in the appropriate patient population, studies suggest the HINTS+ exam can be highly sensitive for detecting posterior circulation stroke.

Who should learn the HINTS+ exam?

Clinicians who regularly assess dizziness may benefit from learning this exam, including:

• Physiotherapists

• Vestibular therapists

• Chiropractors

• Neurologic rehabilitation clinicians

• Emergency clinicians

Where can I learn the HINTS+ exam?

A full clinical walkthrough of the HINTS+ exam is available in this course: HINTS+ Exam Demystified: Differentiating Central vs. Peripheral Causes of Acute Dizziness.