The HINTS+ Exam: Differentiating Acute Vertigo and Stroke

Written by: James Demetrious, DC, DABCO

Diplomate, American Board of Chiropractic Orthopedists

Acute Vertigo or Stroke

Can you distinguish acute vertigo due to central stroke versus peripheral inner ear, BPPV, or vestibular neuronitis etiologies without advanced imaging?

The HINTS+ Battery of Tests

HINTS+ testing is utilized by some emergency physicians, oto-neurologists, and physicians to differentiate inner ear disorders from stroke in patients with acute dizziness and vertigo.

HINTS+ is the acronym for Head Impulse, Nystagmus, Test of Skew, + bedside test of hearing.

Tarnutzer and Edlow report that it is utilized because of,

“Missed or delayed diagnosis of posterior circulation stroke is an important and, unfortunately, a common problem [8,44–46].”

The authors report, HINTS+ is effective, ”

“For the bedside clinical assessment of acutely dizzy patients meeting the diagnostic criteria of an acute vestibular syndrome, looking for subtle oculomotor signs is key to increasing diagnostic accuracy.”

They offer the following table to describe the tests and interpretation of observed findings:

GRACE-3 Guidelines

Due to high sensitivity and specificity, the HINTS+ battery of tests is recommended by GRACE-3 (Guidelines for Reasonable and Appropriate Care in the Emergency Department):

Utilization in Chiropractic?

There is one aspect of the HINTS+ examination that requires due consideration. During the Head Impulse portion of the HINTS+ exam, the patient’s head is passively rotated, rapidly left and then right, to elicit a response.

Should such rapid movement be performed on a patient who has a developing cervical artery dissection (CAD) or thrombi? Is it possible that examination could precipitate thromboembolism?


1.) Tarnutzer AA and Edlow JA.Bedside Testing in Acute Vestibular Syndrome—Evaluating HINTS Plus and Beyond—A Critical Review. Audiol. Res. 2023, 13, 670–685.

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The information provided in this article and all PostGradDC coursework should not be considered standards of care. We offer this information for educational purposes only. This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or qualified healthcare provider with any questions you may have regarding medical conditions or treatment.