Vestibular migraine
Episodic vertigo with migraine features. Why HINTS is not validated outside acute vestibular syndrome — and what to look for instead.
Clinical picture
Recurrent episodes of vertigo lasting minutes to 72 hours, often with migrainous headache, photophobia, phonophobia, or visual aura. Diagnosis is by the Bárány Society / International Headache Society criteria, not by HINTS5,6.
HINTS during an attack
Between attacks the exam is typically normal. During an attack, oculomotor findings are heterogeneous — central or peripheral features may appear, and direction-changing nystagmus has been described. The clinical context (recurrent attacks, migraine features, return to baseline between episodes) distinguishes vestibular migraine from acute vestibular syndrome.
Why HINTS is not the right tool here
HINTS was developed and validated specifically for the continuousacute vestibular syndrome3. Episodic vertigo — vestibular migraine, BPPV, Ménière's — falls outside its validated domain. Applying HINTS to these patients can produce misleading results.
When a patient with recurrent vertigo presents during their first or worst-ever attack, distinguishing vestibular migraine from posterior circulation TIA can be difficult. Vascular risk factors, accompanying focal neurology, and persistence of symptoms beyond the expected migraine duration should prompt vascular workup regardless of HINTS.