HINTS Exam Accuracy Refined to Improve Stroke Diagnosis
A new review clarifies that the HINTS exam should be used only for patients with persistent dizziness and nystagmus.
Updated on Sept. 25, 2026 in Stroke
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A recently published review establishes stricter criteria for using the HINTS vestibular examination to ensure diagnostic accuracy. The findings aim to reduce misdiagnoses of stroke in patients presenting with dizziness.
Why it matters
Inappropriate use of the HINTS exam has frequently led to unnecessary stroke workups or missed diagnoses when patients are tested without meeting specific clinical criteria. Applying the test only when indicated helps providers reliably distinguish between peripheral vestibular disorders and life-threatening central causes like stroke.
A review published in JAMA Neurology found that the HINTS exam, which includes head impulse, nystagmus, and test of skew, is often applied outside its validated population. Retrospective data showed that 71%-97% of patients received the test despite lacking nystagmus at rest.
The players
JAMA Neurology
A peer-reviewed medical journal that publishes original research and commentary on clinical neurology and stroke care.
The details
The HINTS exam, introduced in 2009, is designed to identify serious central causes of acute dizziness, such as a stroke, by evaluating oculomotor signs. The protocol includes a head impulse test, nystagmus assessment, and a test of skew, with an additional hearing assessment, known as HINTS+, used to identify cerebellar artery strokes. Evidence suggests that these tests are misleading if performed on patients who do not present with nystagmus at rest, where a standard neurologic gait assessment is more appropriate.
Timeline
The HINTS bedside tool was introduced in 2009.
The review was published online in JAMA Neurology on September 21, 2026.
Health Landscape
The HINTS bedside tool has become a critical component of emergency neurologic evaluations since 2009. This review updates clinical practice by defining the specific patient population where the exam provides reliable diagnostic information.
If you or a family member experience sudden, persistent dizziness, be aware that diagnostic tests like HINTS are designed for specific clinical scenarios. It is worth discussing with your doctor how emergency clinicians verify the cause of vertigo to ensure that appropriate testing is used for your symptoms.
The takeaway
The HINTS exam is a specialized tool intended for patients with persistent dizziness and observable eye movement abnormalities. When evaluating sudden dizziness, clinical teams must balance the use of targeted exams like HINTS with broader neurologic assessments to prevent both missed strokes and unnecessary testing.
Further reading
For more information on diagnostic protocols and emergency care, visit Stroke.
Source note: This article includes information reported by Medscape.
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