Bedside vestibular exam: nystagmus, head impulse, HINTS and Dix-Hallpike
- Examination
A few eye and head tests at the bedside separate inner-ear vertigo from stroke and diagnose positional vertigo in minutes.
What it is
The bedside vestibular exam answers two questions: is this vertigo peripheral (inner ear or vestibular nerve) or central (brainstem or cerebellum), and is it positional? The history chooses the test. In continuous acute vertigo with nystagmus (the acute vestibular syndrome), the HINTS exam (head impulse, nystagmus, test of skew) separates vestibular neuritis from posterior circulation stroke. In brief vertigo triggered by lying down or turning in bed, the Dix-Hallpike manoeuvre diagnoses posterior canal benign paroxysmal positional vertigo. Gait, Romberg and a neurological exam complete the picture.
Findings and interpretation
- Peripheral spontaneous nystagmus is unidirectional and horizontal; central nystagmus changes direction or is purely vertical or torsional.
- An abnormal head impulse (corrective saccade toward the tested side) indicates a peripheral lesion on that side.
- In the acute vestibular syndrome a normal head impulse is worrying: it points to a central cause.
- Skew deviation (vertical misalignment on cover testing) is a central sign.
- Posterior canal BPPV: torsional nystagmus toward the affected ear on Dix-Hallpike, short latency, short duration and fatigue.
- Patients with typical BPPV and no other abnormal signs do not need imaging.
How it is done
- Take the history first: brief positional episodes call for Dix-Hallpike; continuous vertigo for hours or days calls for HINTS.
- Look for spontaneous nystagmus in primary gaze and on looking right and left; note the direction of the fast phase and whether it changes.
- Fixation can suppress nystagmus; use lenses or a blank card that remove fixation if available.
- Head impulse: hold the head while the patient looks at the examiner's nose, turn it quickly and briefly to each side and watch for a catch-up saccade.
- Test of skew: cover one eye and then quickly the other; a vertical refixation movement means skew deviation.
- Check limb coordination and gait; marked imbalance or inability to walk is a central warning sign.
- Dix-Hallpike: sitting, head turned 45° toward the tested ear, lay the patient back quickly with the head extended slightly over the table edge.
- Watch the eyes for at least 30 seconds: latency, direction, duration, then sit the patient up and test the other side.
- Finish with the Romberg test and tandem gait and record each finding in words.
HINTS in the acute vestibular syndrome
| Test | Peripheral (vestibular neuritis) | Central (stroke) |
|---|---|---|
| Head impulse | Abnormal: corrective saccade | Normal |
| Nystagmus | One direction, horizontal | Direction-changing, vertical or torsional |
| Test of skew | No skew deviation | Skew deviation present |
Common mistakes
- Using HINTS in brief positional vertigo or without ongoing nystagmus: it is valid only in the acute vestibular syndrome.
- Reading a normal head impulse as reassuring in continuous acute vertigo, when it actually points to a central cause.
- Giving antihistamines or benzodiazepines before testing: they suppress the nystagmus of the Dix-Hallpike and hide the diagnosis.
- Ordering imaging for every typical BPPV instead of treating it at the bedside.
Next step / Initial management
- Any central sign on HINTS, new neurological signs or sudden imbalance with speech or vision trouble: emergency referral the same hour for stroke workup and urgent brain imaging.
- Positive Dix-Hallpike: treat at the bedside with a repositioning manoeuvre (Epley); medicines are not routinely needed.
- Peripheral pattern (vestibular neuritis): short course of vestibular suppressants and antiemetics, an optional corticosteroid course and early vestibular rehabilitation.
- Refer to ENT (routine) for recurrent vertigo with hearing loss, tinnitus or ear fullness (possible Ménière disease) or BPPV that does not respond to repositioning.
Test yourself
Think of the answer, then tap the question to see it.
A 65-year-old has 12 hours of continuous vertigo, left-beating nystagmus, a normal head impulse and a vertical skew deviation. What is the concern?
A central cause (posterior circulation stroke): a normal head impulse and skew deviation are central signs; urgent imaging.
Which Dix-Hallpike finding is typical of posterior canal BPPV?
Torsional nystagmus toward the lower ear after a short latency, lasting under a minute and fading with repetition.
What does a corrective saccade on the head impulse test indicate?
A deficient vestibulo-ocular reflex on that side: a peripheral vestibular lesion.
Which positional nystagmus features suggest a central lesion?
No latency, no fatigue, persistence while the position is held, or vertical or direction-changing nystagmus.
Elsewhere in DurgiPedia
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Vestibular Neuronitis (MSD Manual Professional Edition, 2026); Benign Paroxysmal Positional Vertigo (MSD Manual Professional Edition, 2025); Balance Disorders (NIDCD, National Institutes of Health, 2018); Signs and Symptoms of Stroke (Centers for Disease Control and Prevention, 2026).
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Representative model, for educational purposes only.