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OtolaryngologyDiagnostic

Acute Vertigo Evaluation (HINTS & BPPV)

Acute Vertigo Evaluation (HINTS & BPPV): Acute Vertigo / Dizziness → Classify Vestibular Syndrome → Triggered EVS → Suspect BPPV → Dix-Hallpike Test → D...

Pathway Overview

17 steps

Algorithm Steps

17 total

  1. 01Start

    Acute Vertigo / Dizziness

    Patient presents with vertigo (room spinning), dizziness, or imbalance.

  2. 02Decision

    Classify Vestibular Syndrome

    AVS: Continuous dizziness >24h with nystagmus. Triggered EVS: Brief episodes with head movement. Spontaneous EVS: Episodes without trigger.

  3. 03Action

    Triggered EVS → Suspect BPPV

    Brief vertigo (<1 min) triggered by head position changes. 90% of triggered EVS is BPPV. Perform Dix-Hallpike test.

  4. 04Action

    Dix-Hallpike Test

    Patient sitting, turn head 45°, rapidly lie back with head hanging. Watch for upbeat-torsional nystagmus with latency (2-20 sec). Positive = posterior canal BPPV.

  5. 05Decision

    Dix-Hallpike Positive?

    Upbeat-torsional nystagmus with latency confirms posterior canal BPPV.

  6. 06Action

    Epley Maneuver (CRP)

    Canalith Repositioning: Turn head 90° to opposite side, roll onto that side, sit up slowly. Hold each position 30 seconds. 70-80% success rate.

  7. 07Outcome

    BPPV Treated

    Symptoms usually resolve immediately. Can recur (30-50%). Teach home Epley if recurrent.

  8. 08Action

    AVS: Check for Nystagmus

    Acute Vestibular Syndrome with continuous symptoms. Look for spontaneous nystagmus. If present → HINTS exam.

  9. 09Decision

    Nystagmus Present?

    HINTS exam only valid if spontaneous nystagmus is present.

  10. 10Action

    Perform HINTS Exam

    H: Head Impulse. I: Nystagmus type. TS: Test of Skew. HINTS is 92.9% sensitive for stroke - BETTER than MRI in first 48 hours.

  11. 11Decision

    HINTS Result?

    PERIPHERAL: Positive head impulse + direction-fixed nystagmus + no skew. CENTRAL: ANY of negative head impulse, direction-changing nystagmus, or skew.

  12. 12Action

    Peripheral: Vestibular Neuritis

    Supportive care, antiemetics PRN (limit 2-3 days). Consider short-term steroids. Vestibular rehabilitation.

  13. 13Outcome

    Vestibular Neuritis Recovery

    Most recover in 1-3 weeks. Vestibular PT accelerates recovery. Follow-up with ENT.

  14. 14Warning

    ⚠️ Central: Suspect Stroke

    HINTS central = posterior circulation stroke until proven otherwise. Activate stroke protocol. MRI (not CT). Neurology STAT.

  15. 15Action

    Stroke Workup

    MRI brain with DWI. CTA head/neck. Consider thrombolysis if within window. Admit to stroke unit.

  16. 16Warning

    ⚠️ CT is NOT Adequate

    GRACE-3: Do NOT use CT to rule out stroke in AVS. CT sensitivity only 29% for posterior fossa stroke. MRI required.

  17. 17Action

    No Nystagmus: Other Causes

    Consider: Orthostatic hypotension, cardiac arrhythmia, medication effects, anemia, hypoglycemia, anxiety.

  18. Path rejoins step 08Shared downstream outcome

Guideline Source

GRACE-3: Acute Dizziness and Vertigo in the ED + StatPearls

View 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 exam requires training (6-8 hours + supervised practice)
  • Only valid in patients WITH nystagmus
  • Does not replace clinical judgment for stroke risk
  • BPPV variants (horizontal canal) require different maneuvers

Applicable Regions

USEU
Version 1Next review: 2027-01-11

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Frequently Asked Questions

What is the Acute Vertigo Evaluation (HINTS & BPPV)?

The Acute Vertigo Evaluation (HINTS & BPPV) 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 ED + StatPearls.

What guideline is the Acute Vertigo Evaluation (HINTS & BPPV) based on?

This algorithm is based on GRACE-3: Acute Dizziness and Vertigo in the ED + StatPearls.

What are the limitations of the Acute Vertigo Evaluation (HINTS & BPPV)?

Known limitations include: HINTS exam requires training (6-8 hours + supervised practice); Only valid in patients WITH nystagmus; Does not replace clinical judgment for stroke risk; BPPV variants (horizontal canal) require different maneuvers. Individual patient factors may require deviation from these recommendations.

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