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Acute Vertigo and Dizziness Evaluation (HINTS Plus and BPPV), Adults

Acute Vertigo and Dizziness Evaluation (HINTS Plus and BPPV), Adults: Acute Dizziness or Vertigo (Adult ED) → Red Flags First: Focal Deficit, Severe Hea...

Pathway Overview

27 steps

Algorithm Steps

27 total

  1. 01Start

    Acute Dizziness or Vertigo (Adult ED)

    Adults with new dizziness, vertigo or unsteadiness for less than 2 weeks, with no obvious medical or neurological cause.

  2. 02Warning

    Red Flags First: Focal Deficit, Severe Headache, Cardiac Signs

    Adults only. Children: use a paediatric pathway. Check these before syndrome-based testing.

    • New focal deficit (weakness, speech, diplopia, swallowing, facial numbness) or reduced GCS: code stroke now; do not wait for HINTS
    • Sudden severe headache or neck pain: exclude haemorrhage and vertebral artery dissection (CT and CTA)
    • Syncope, chest pain, palpitations or dyspnoea: ECG; consider arrhythmia or PE
  3. 03Decision

    Which Vestibular Syndrome? (Timing and Triggers)

    AVS: continuous dizziness lasting days. Triggered EVS: brief episodes (seconds to 1 min) brought on by head or body position. Spontaneous EVS: episodes of minutes to hours with no trigger.

  4. Triggered EVS
  5. 04Action

    Triggered EVS (Positional): Suspect BPPV

    Brief vertigo on lying down, rolling over or looking up; no symptoms at rest. Do the Dix-Hallpike test.

    • Dizziness only on standing up: check lying and standing BP (orthostatic hypotension)
    • No CT or CTA for typical positional vertigo (GRACE-3)
    • Do not treat BPPV with vestibular suppressants
  6. 05Action

    Dix-Hallpike Test (Both Sides)

    Sitting, head turned 45° to the test side. Lie back quickly with the head hanging slightly below horizontal. Watch the eyes.

    • Unstable or very stiff neck (recent neck injury, atlantoaxial instability, severe RA) or vertebral artery disease: do not hang the head; use the side-lying test or refer
    • Positive: upbeat-torsional nystagmus toward the lower ear, after a latency of seconds, lasting under 1 min, with vertigo
    • Repeat on the other side
  7. 06Decision

    Dix-Hallpike Result?

    Typical: brief upbeat-torsional nystagmus. Horizontal or no nystagmus: do the supine roll test. Atypical (downbeat, persistent, other neuro signs): possible central cause.

  8. Typical upbeat-torsional
  9. 07Action

    Typical Posterior Canal BPPV: Epley Manoeuvre Now

    Treat the affected side at diagnosis (GRACE-3 strong recommendation). Hold each position 30-60 s and until nystagmus and vertigo stop. Unstable or very stiff neck: refer rather than extend the neck.

    • 1. Dix-Hallpike position with the affected ear down
    • 2. Turn the head 90° to the other side, neck still extended
    • 3. Roll onto that side with the head turned further, nose down
    • 4. Sit up; repeat the manoeuvre if still positive
  10. 08Outcome

    Positional Vertigo: Discharge Plan

    Treated BPPV with relief: no imaging and no activity restrictions; it can recur, return for a repeat manoeuvre. No response to manoeuvres, atypical nystagmus or new neuro signs: MRI (not CT) and specialist review before discharge. Untreated or unclear cases: vestibular specialist review within 72 h.

  11. Horizontal or none
  12. 09Action

    Horizontal or No Nystagmus: Supine Roll Test

    Tests the horizontal canal. Supine with the head raised 30°, turn the head quickly to each side and watch for up to 1 min. Stiff or unstable neck: log roll the whole body instead.

    • Brief horizontal nystagmus beating toward the lower ear: horizontal canal BPPV
    • Treat with Lempert (barbecue) roll or Gufoni manoeuvre if trained; if not, specialist review within 72 h
    • Persistent nystagmus beating away from the lower ear: possible central cause; MRI
    • No nystagmus on either test: check lying and standing BP; consider other causes
  13. Path rejoins step 08Shared downstream outcome
  14. Atypical
  15. 10Warning

    Atypical Positional Nystagmus: Possible Central Cause

    A posterior fossa lesion can mimic BPPV (central positional vertigo).

    • Downbeat, purely torsional, persistent or non-fatiguing nystagmus, or any other neuro sign
    • Do not diagnose BPPV; MRI brain (not CT)
    • Neurology review before discharge
  16. 11Outcome

    Possible Central Positional Vertigo: MRI and Neurology

    MRI brain (with contrast if acute stroke is not suspected) and neurology review. Acute stroke features: follow the stroke work-up.

  17. AVS (continuous)
  18. 12Action

    AVS: Continuous Vertigo; Examine for Nystagmus

    Continuous dizziness for days, with nausea or vomiting, head-motion intolerance or unsteady gait. Stroke causes about 10-25% of AVS.

    • Look for nystagmus in straight-ahead gaze and on side gaze
    • Do not use CT or CTA to rule out stroke: CT misses most early posterior fossa infarcts
    • CT first if haemorrhage is suspected (severe headache, confusion or reduced GCS, hemiparesis, cannot sit or stand upright): MRI would delay treatment
  19. 13Decision

    Spontaneous or Gaze-evoked Nystagmus Present?

    HINTS is valid only in AVS with nystagmus. Without nystagmus, a normal head impulse would falsely suggest stroke.

  20. If Yes
    1. 14Action

      Nystagmus Present: HINTS Plus by a Trained Clinician

      Four bedside tests. Not trained in HINTS, or unsure of the result: do not rely on it; get MRI-DWI or expert review.

      • Head impulse: corrective saccade is peripheral; normal (no saccade) is central
      • Nystagmus: direction-fixed horizontal (may have a torsional part) is peripheral; direction-changing, mainly vertical or purely torsional is central
      • Test of skew: vertical re-fixation on alternate cover is central
      • Finger-rub hearing: new one-sided hearing loss is central (AICA stroke)
    2. 15Decision

      All Four HINTS Plus Findings Peripheral?

      Peripheral only if: abnormal head impulse, direction-fixed horizontal nystagmus, no skew and no new hearing loss. Any central sign, or equivocal: treat as central.

    3. If Yes
      1. All peripheral
      2. 16Decision

        Peripheral HINTS Plus: Walks Unaided, No Focal Signs?

        Check before discharge. Cannot stand or walk without support, limb ataxia, dysarthria, diplopia, dysphagia, Horner syndrome or facial numbness: treat as central.

      3. If Yes
        1. Walks unaided, no focal signs
        2. 17Action

          Peripheral and Walks Unaided: Vestibular Neuritis

          No imaging needed when a trained clinician finds peripheral HINTS plus and the patient walks unaided.

          • Antiemetic or vestibular suppressant for no more than 3-5 days. Parkinson disease or Lewy body dementia: avoid prochlorperazine and metoclopramide
          • Older adults: lowest dose; avoid anticholinergic antihistamines where possible (falls, delirium)
          • Steroids: shared decision if within 3 days of onset (very low certainty evidence). Poorly controlled diabetes or bipolar disorder with mania: relative contraindication
          • Refer for vestibular physiotherapy
        3. 18Outcome

          Vestibular Neuritis: Discharge with Follow-up

          Most improve over days to weeks. GP and ENT or neurology follow-up; vestibular physiotherapy. Return at once for new weakness, speech, vision or swallowing problems, severe headache or inability to walk.

        If No
        1. Severe unsteadiness or focal sign
        2. 19Warning

          Central Signs: Suspect Posterior Circulation Stroke

          Any central HINTS plus sign, equivocal HINTS, cannot walk unaided, or any focal sign. Stroke until proven otherwise.

          • Call the stroke team now; check the reperfusion time window
          • A normal CT does not exclude ischaemic stroke
          • MRI in the first 48 h misses about 10-22% of these strokes
        3. 20Action

          Stroke or TIA Work-up: MRI-DWI and Vessel Imaging

          Follow the local acute stroke or TIA pathway with the stroke team.

          • In the reperfusion window: code-stroke CT with CTA to exclude haemorrhage and find basilar or vertebral occlusion
          • Stroke-protocol MRI (DWI) with MRA; TIA concern: CTA or MRA (GRACE-3)
          • IV thrombolysis only if eligible after the full contraindication check; BP below 185/110 mmHg first
          • Basilar or other large vessel occlusion: urgent thrombectomy assessment
        4. 21Warning

          Early MRI Negative Does Not Exclude Stroke or TIA

          Early DWI can miss small posterior circulation strokes. Central signs: do not discharge.

          • Central signs: do not diagnose vestibular neuritis; admit or observe with neurology review
          • Repeat MRI if signs persist (delayed MRI after 72 h is more sensitive)
          • TIA concern: urgent TIA assessment per the local pathway, even if MRI is normal
        5. 22Outcome

          Stroke or TIA: Stroke Team Care

          Stroke: admit to a stroke unit. TIA: urgent TIA assessment per the local pathway. Large cerebellar infarct: watch for oedema and hydrocephalus; urgent neurosurgical review if conscious state falls. Start secondary prevention once haemorrhage is excluded; no antiplatelet within 24 h of thrombolysis unless the stroke team advises.

      If No
      1. Any central or equivocal
      2. Path rejoins step 19Shared downstream outcome
    If No
    1. 23Decision

      No Nystagmus: Walks Unaided, No Focal Signs?

      Grade gait: ask the patient to sit, stand and walk. Cannot walk without support or cannot stand unaided (grade 2-3) suggests stroke.

    2. If Yes
      1. Walks unaided, no focal signs
      2. 24Outcome

        No Nystagmus, Walks Unaided: Look for Medical Causes

        Check lying and standing BP, ECG, glucose, blood count, drugs and infection. Mild unsteadiness still carries some stroke risk: with vascular risk factors or persisting symptoms, get MRI or neurology review before discharge.

      If No
      1. Cannot walk unaided or focal sign
      2. Path rejoins step 19Shared downstream outcome
  21. Spontaneous EVS
  22. 25Warning

    Spontaneous Episodic Vertigo: Consider Posterior Circulation TIA

    Episodes of minutes to hours with no trigger. The exam is often normal between episodes.

    • Full exam: cranial nerves, visual fields, eye movements, limb coordination, gait
    • Do not use CT to decide central versus peripheral
    • Also consider arrhythmia (ECG) and PE
  23. 26Decision

    Concern for TIA?

    First-ever or recent-onset episode, vascular risk factors, neck pain, or any transient neuro symptom (diplopia, dysarthria, numbness, weakness).

  24. If Yes
    1. TIA concern
    2. Path rejoins step 20Shared downstream outcome
    If No
    1. TIA unlikely
    2. 27Outcome

      TIA Unlikely: Episodic Vestibular Disorder

      Vestibular migraine is most common; Menière disease if one-sided hearing loss, tinnitus or ear fullness. Refer to a vestibular specialist and GP. Return at once for new neuro symptoms.

Guideline Source

GRACE-3: Acute Dizziness and Vertigo in the Emergency Department (SAEM; Edlow et al., Acad Emerg Med 2023)

DOI: 10.1111/acem.14728View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • HINTS plus is reliable only when done by a trained clinician; if not trained, use MRI-DWI or expert review
  • CT and early MRI (first 48 h) can miss posterior circulation stroke
  • Adults in the ED with dizziness under 2 weeks; not for children or chronic dizziness
  • Horizontal canal and other BPPV variants need a trained examiner or specialist referral

Contraindicated Populations

Children (under 18 years)New focal neurological deficit or reduced GCS: use the acute stroke pathway firstDizziness with an obvious medical cause (e.g. hypoglycaemia, hypotension, intoxication)

Applicable Regions

AUUSEUglobal

AU: Reperfusion eligibility and agent (tenecteplase or alteplase) per the Australian and New Zealand Living Clinical Guidelines for Stroke Management. Prochlorperazine is the usual short-course vestibular suppressant; avoid it in Parkinson disease or Lewy body dementia.

US: GRACE-3 (SAEM 2023).

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Acute Vertigo and Dizziness Evaluation (HINTS Plus and BPPV), Adults?

The Acute Vertigo and Dizziness Evaluation (HINTS Plus and BPPV), Adults is a diagnostic clinical algorithm for Otolaryngology. It provides a structured decision tree to guide clinical decision-making, based on GRACE-3: Acute Dizziness and Vertigo in the Emergency Department (SAEM; Edlow et al., Acad Emerg Med 2023).

What guideline is the Acute Vertigo and Dizziness Evaluation (HINTS Plus and BPPV), Adults based on?

This algorithm is based on GRACE-3: Acute Dizziness and Vertigo in the Emergency Department (SAEM; Edlow et al., Acad Emerg Med 2023) (DOI: 10.1111/acem.14728).

What are the limitations of the Acute Vertigo and Dizziness Evaluation (HINTS Plus and BPPV), Adults?

Known limitations include: HINTS plus is reliable only when done by a trained clinician; if not trained, use MRI-DWI or expert review; CT and early MRI (first 48 h) can miss posterior circulation stroke; Adults in the ED with dizziness under 2 weeks; not for children or chronic dizziness; Horizontal canal and other BPPV variants need a trained examiner or specialist referral. Individual patient factors may require deviation from these recommendations.

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