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Update on HINTS Plus, With Discussion of Pitfalls and Pearls

Kattah, Jorge C., MD

Journal of Neurologic Physical Therapy: April 2019 - Volume 43 - Issue - p S42–S45
doi: 10.1097/NPT.0000000000000274
Special Interest Articles

Background and Purpose: The team that manages acute vertigo in patients requires multispecialty skills. This special interest article offers a simplified list of common pitfalls to be avoided when applying the HINTS (Head-Impulse, Nystagmus, Test-of-Skew) Plus examination protocol in patients with acute vertigo. Benign paroxysmal positional vertigo is the most frequent cause of positional vertigo. The lack of systematic evaluation of symptom duration and triggers, and/or incomplete target examination, leads to improper diagnosis and management. Pitfalls to avoid and pearls to apply are offered to avoid misclassification of acute vertigo.

Summary of Key Points: Appropriate, expeditious treatment implemented upon diagnostic certainty by the first health professional evaluating the patient is key to a good outcome. The absence of a typical positional nystagmus is particularly concerning for an alternative diagnosis. Misclassification of the type of vertigo leads to potential diagnostic error. The HINTS Plus examination is useful when applied to the correct clinical scenario. The most common misclassification of vertigo relates to an inability to detect spontaneous nystagmus suppressed by visual fixation and subsequent classification and treatment for positional vertigo. The second most common classification relates to inadequate evaluation of the HINTS Plus examination.

Recommendations for Clinical Practice: Through an organized evaluation of the acutely vertiginous patient, common pitfalls in the classification of vertigo can be avoided. Such an evaluation leads to identification of those patients who require canal repositioning maneuvers and those who need referral for evaluation of other causes.

Neurology Department, University of Illinois College of Medicine at Peoria.

Correspondence: Jorge C. Kattah, MD, Neurology Department, University of Illinois College of Medicine at Peoria, Peoria, IL 61605 (

The author declares no conflict of interest.

© 2019 Academy of Neurologic Physical Therapy, APTA