Acute Continuous Vertigo
Vertigo/dizziness with nystagmus, ongoing >24h
All Pathways
NeurologyDiagnostic
Acute Vertigo Evaluation (HINTS Exam)
Acute Vertigo Evaluation (HINTS Exam): Acute Continuous Vertigo → Confirm Acute Vestibular Syndrome (AVS) → Not AVS.
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action Confirm Acute Vestibular Syndrome (AVS)
Criteria for HINTS application
- Acute onset vertigo/dizziness
- Continuous symptoms (not episodic)
- Nystagmus present on examination
- Nausea/vomiting, gait unsteadiness
- Duration >24 hours typical
03Action Not AVS
HINTS not applicable
- Episodic vertigo → consider BPPV, Meniere's
- No nystagmus → different workup
- Chronic dizziness → vestibular clinic
- Light-headedness → orthostatic, cardiac
04Action Assess Stroke Risk Factors
Higher index of suspicion if present
- Age >50
- Vascular risk factors (HTN, DM, smoking)
- History of stroke/TIA
- Atrial fibrillation
- Neck pain (dissection risk)
05Action Perform HINTS Exam
Head Impulse, Nystagmus, Test of Skew
- Requires training for accuracy
- Sensitivity >95% for stroke if done correctly
- More sensitive than early MRI
- Best within 48h of symptom onset
06Decision Head Impulse Test (HIT)
Assess VOR
- Turn head rapidly, watch for catch-up saccade
- POSITIVE (abnormal): catch-up saccade = peripheral
- NEGATIVE (normal): no saccade = concerning for central
07Decision HINTS Interpretation
Central or Peripheral?
- PERIPHERAL: Abnormal HIT + unidirectional nystagmus + no skew
- CENTRAL: ANY dangerous sign present
- Dangerous: Normal HIT, direction-changing nystagmus, or skew
08Action HINTS Peripheral
Likely vestibular neuritis
- All 3 components reassuring
- Abnormal HIT (catch-up saccade)
- Unidirectional nystagmus
- No skew deviation
- Also check hearing (AIDP variant)
09Action Check Hearing (Finger Rub)
HINTS-Plus
- New unilateral hearing loss suggests AICA stroke
- Even if HINTS peripheral, hearing loss = MRI
- AICA supplies inner ear and brainstem
10Action Treat Vestibular Neuritis
Symptomatic management
- Vestibular suppressants short-term (meclizine, dimenhydrinate)
- Antiemetics PRN
- Early vestibular rehabilitation
- Steroids controversial (may help)
- Recovery over weeks
11Outcome Discharge with Follow-up
Peripheral vertigo care
- ENT or neurology follow-up
- Vestibular PT referral
- Return if new symptoms
12Action MRI with DWI
Posterior fossa protocol
- MRI more sensitive than CT for posterior stroke
- DWI may be falsely negative in first 24-48h
- Consider repeat MRI if high clinical suspicion
- MRA to evaluate vertebrobasilar system
13Action Stroke Workup/Treatment
Acute stroke protocol
- Neurology consult
- Consider tPA if within window
- Thrombectomy if LVO
- Admit to stroke unit
- Secondary prevention workup
14Outcome Admit for Stroke Care
Inpatient management
- Path rejoins step 10Shared downstream outcome
15Warning ⚠️ HINTS Central / Dangerous
Any one dangerous sign = stroke suspected
- Normal head impulse test
- Direction-changing nystagmus
- Skew deviation present
- Suspect posterior circulation stroke
- MRI urgently indicated
- Path rejoins step 12Shared downstream outcome
16Decision Nystagmus Pattern
Direction-changing or unidirectional?
- UNIDIRECTIONAL: beats same direction = peripheral
- DIRECTION-CHANGING: changes with gaze = central
- Pure vertical/torsional = central
- Path rejoins step 07Shared downstream outcome
17Decision Test of Skew
Alternate cover test
- Cover/uncover each eye
- Watch for vertical correction
- PRESENT (abnormal): vertical realignment = central
- ABSENT (normal): no vertical misalignment = peripheral
- Path rejoins step 07Shared downstream outcome
Guideline Source
GRACE-3: Acute Dizziness and Vertigo in the Emergency Department
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- HINTS requires trained examiner for accuracy
- Only applies to acute vestibular syndrome (AVS)
- Not for episodic vertigo or chronic dizziness
- False negatives possible even with proper HINTS
Applicable Regions
USEUglobal
EU: Similar recommendations from ESO
US: GRACE-3 guidelines 2023
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Acute Vertigo Evaluation (HINTS Exam)?
The Acute Vertigo Evaluation (HINTS Exam) is a diagnostic clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on GRACE-3: Acute Dizziness and Vertigo in the Emergency Department.
What guideline is the Acute Vertigo Evaluation (HINTS Exam) based on?
This algorithm is based on GRACE-3: Acute Dizziness and Vertigo in the Emergency Department (DOI: 10.1111/acem.14728).
What are the limitations of the Acute Vertigo Evaluation (HINTS Exam)?
Known limitations include: HINTS requires trained examiner for accuracy; Only applies to acute vestibular syndrome (AVS); Not for episodic vertigo or chronic dizziness; False negatives possible even with proper HINTS. Individual patient factors may require deviation from these recommendations.
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