Algorithm for Patient presenting with Vertigo
Do HINTS Exam
HINTS Exam
1. Head Impulse test of vestibulo-ocular reflex function
2. Observation for Nystagmus in primary, right, and left gaze
3. Alternate cover Test for Skew deviation.
Head Impulse
1. Have pt fix their eyes on your nose
2. Move their head in the horizontal plant from left to right
3. When the head is turned towards the normal side the vestibular ocular reflex remains
intact and eyes continue to fixate on the visual target
4. When the head is turned towards the affected side, the vestibular ocular reflex FAILS and
the eyes make a corrective saccade to re-fixate on the visual target. It is reassuring if the
reflex is abnormal (due to dysfunction of the peripheral nerve) ie abnormal means it is a
peripheral cause of vertigo.
Nystagmus
Peripheral causes of vertigo (ie BPV) can give HORIZONTAL nystagmus but ONLY in one
direction. Move the head right, left or up and down and the nystagmus will ONLY be in one
direction.
However if you have the patient look to the left and there is left beating nystagmus and
then have the patient look to the right and there is right beating nystagmus, that is known as
direction changing nystagmus and that is BAD. ie occurs with central cause of nystagmus.
Vertical nystagmus is always BAD.
Test of Skew
Skew is also known as vertical dysconjugate gaze and is a sign of a central lesion.
1. Have pat look at your nose with their eyes and then cover one eye.
2. Then rapidly uncover the eye and quickly look to see if the eye moves to re-align.
3. Repeat on each eye.
4. (or if pt complains of binocular diplopia that is a positive test too)
SUMMARY
Head Impulse
You want the head impulse test to be ABNORMAL to reassure you the patient has a
peripheral cause of vertigo.
Nystagmus
You want the nystagmus to be fast beating in ONLY ONE DIRECTION to reassure you the
patient has a peripheral cause of vertigo.
Test of Skew
You want PERFECT VERTICAL ALIGNMENT of the eyes to reassure you the patient has
peripheral cause of vertigo.