Bedside guide for positional vertigo and acute dizziness. First decide: is this positional (brief, triggered by head movement → likely BPPV) or a continuous acute vestibular syndrome (then use HINTS to separate peripheral from central)?
Affected side
Sets the Dix-Hallpike / Epley wording below
The affected side is the one that reproduces vertigo & nystagmus on Dix-Hallpike (head turned toward that ear).
Dix-Hallpike test
Diagnose posterior-canal BPPV
Patient sitting; turn head 45° toward the right side.
Lie them back quickly to supine with the head extended ~20° below the horizontal (hanging off the couch), keeping the 45° turn.
Watch the eyes for 30 s and ask about vertigo.
Positive (posterior-canal BPPV):
Latency 5–20 s before nystagmus starts.
Up-beating & torsional nystagmus — top poles of the eyes beat toward the lower (right, affected) ear.
Crescendo–decrescendo, resolves within ~60 s.
Fatigues on repetition; reverses on sitting up.
Epley manoeuvre
Treat right posterior-canal BPPV · hold each ~30 s
1Sit upright on the couch; turn the head 45° toward the right (affected) side.
2Lie back quickly to supine, head extended ~20° below horizontal, still turned 45° to the right. Hold until nystagmus/vertigo settles (~30 s).
3Turn the head 90° to the left side (now 45° toward the unaffected ear), staying supine. Hold ~30 s.
4Roll onto the left shoulder and turn the head a further 90° so the nose points down toward the floor. Hold ~30 s.
5Sit up slowly to the side, keeping the chin tucked slightly down. Re-test after a short rest; repeat if needed.
0:30Hold each position until nystagmus stops
HINTS exam
Acute continuous vertigo · peripheral vs central
Use only in acute vestibular syndrome (continuous vertigo, nausea, nystagmus, gait unsteadiness) with nystagmus present. A “central” pattern is more sensitive than early MRI for stroke.
Component
Peripheral (reassuring)
Central (worrying)
HI — Head Impulse
Abnormal — corrective saccade (positive)
Normal — no saccade
N — Nystagmus
Unidirectional, horizontal
Direction-changing or vertical/torsional
TS — Test of Skew
Absent
Present (vertical skew)
INFARCT = Impulse Normal, FAst-phase Alternating, Refixation on Cover Test → any one central feature suggests a stroke; arrange urgent imaging/neurology. Add new deafness (HINTS-plus) as a red flag.
Educational use only. A bedside aide-mémoire, not a substitute for training or examination findings. HINTS is validated only in continuous acute vestibular syndrome with nystagmus and when performed by an experienced examiner; it must not be used for positional or spontaneously-resolved dizziness. Escalate any central feature, new neurology, or red flag. Verify against local pathways.