Reviewed by Dr. Sabrina Berdouk

Acute vertigo is a clinical pattern, not a diagnosis. STANDING organizes the bedside examination of adults with acute vertigo or unsteadiness. Its value depends on selecting the right patient, recognizing the findings and knowing when to escalate.

Start with timing, triggers and urgent threats

Continuous symptoms that worsen with movement are different from brief attacks triggered by a position change. Head movement aggravates many vestibular disorders; that alone does not establish BPPV. Ask about onset, duration, symptom-free intervals and associated neurological or hearing symptoms.

Assess systemic causes and the neurological examination first. New focal deficits or other convincing stroke features require urgent stroke assessment without waiting to finish a bedside algorithm. A normal routine neurological examination does not exclude a posterior-circulation stroke.

For continuous acute vestibular syndrome (AVS) with nystagmus, trained clinicians can use HINTS. Brief triggered episodes call for positional assessment. Resolved spontaneous episodes require a history-led evaluation, including possible TIA; HINTS is not a rule-out test between attacks. GRACE-3.

What STANDING adds

The four steps are spontaneous versus positional nystagmus, nystagmus direction, head impulse testing and standing/gait. Unlike HINTS, STANDING includes positional presentations and patients without nystagmus. It does not replace assessment of presyncope, metabolic illness or other causes of dizziness.

The vestibulo-ocular reflex stabilizes the image during head movement by moving the eyes in the opposite direction. A deficient response allows the eyes to move off target, followed by a corrective saccade. That physiological finding helps localize dysfunction, but it is not synonymous with vestibular neuritis.

Use the sequence, with training and safe technique

1. Spontaneous or positional? Observe for spontaneous nystagmus. If absent, use appropriate positional testing when safe: Dix–Hallpike for suspected posterior-canal BPPV and supine roll testing for horizontal-canal disease. Typical canal-specific findings support BPPV; atypical findings need further assessment. No nystagmus is not a benign diagnosis.

2. Direction. In spontaneous nystagmus, gaze-evoked direction change or vertical beating raises central concern. A horizontal, unidirectional pattern permits the next step but does not exclude stroke. Do not confuse gaze-dependent direction change with the position-dependent changes assessed during BPPV testing.

3. Head impulse. In STANDING, use HIT in the spontaneous, unidirectional horizontal-nystagmus branch. A corrective saccade supports impaired vestibulo-ocular reflex function; a normal response is concerning in the appropriate acute presentation. Neither result should be interpreted alone.

4. Standing and gait. Assess with support available, only as safely tolerated. Inability to stand or walk independently is concerning, particularly without nystagmus. Independent walking does not exclude a central cause. Record baseline mobility and limitations. Original STANDING algorithm.

Do not force head or positional maneuvers when neck movement is unsafe, or gait testing when the patient may fall. This overview is not procedural training. If the examination cannot be completed or interpreted reliably, obtain appropriate expertise and further investigation.

HINTS, hearing and the rest of the examination

HINTS combines head impulse, nystagmus and a test of skew, an assessment of vertical ocular misalignment. Skew is not one of the four original STANDING steps. In the appropriate AVS patient, skew or another central HINTS component warrants central-cause evaluation. An abnormal HIT can occur in stroke. Original HINTS study.

Assess new hearing asymmetry in AVS with nystagmus; HINTS+ adds hearing assessment. Acute unilateral hearing loss can accompany vascular disease and should not automatically be called labyrinthitis. Without nystagmus, focus on gait severity and the wider examination rather than forcing HINTS. Central or equivocal HINTS findings require MRI/MRA or expert-directed assessment. GRACE-3.

What the validation studies actually show

The 2017 single-centre validation enrolled 352 adults and reported 95% sensitivity (95% CI 83–99%) for central vertigo. Examiners had a six-hour workshop, ten proctored examinations and a month of supervised practice. Not everyone underwent imaging; follow-up formed part of the reference assessment. Vanni et al.

In the 2023 French study of 312 patients, sensitivity was 84.8% for trained interns and 89.8% for senior emergency physicians. These are examiner- and cohort-specific estimates, not a universal property of the mnemonic. Gerlier et al.

In the 2025 multicentre study of adults with isolated vertigo, 242 of 456 participants received STANDING. Sensitivity for central causes was 88.2%, specificity 91.6% and negative predictive value 99%. Allocation depended on trained-clinician availability, and not all patients had MRI. The high negative predictive value reflects that study population; it is not a guarantee for an individual patient. STANDING-M.

The cited Italian validations used fixation-reducing Frenzel lenses. Their results should not be transferred automatically to an untrained or equipment-modified examination. Differences in populations, reference standards and training also prevent a simple “STANDING versus HINTS” accuracy ranking.

Two teaching patterns

Peripheral-compatible pattern: The original example describes spontaneous left-beating nystagmus, a corrective saccade on rightward head impulse and unsteady but independent walking. Together these support right-sided vestibular hypofunction. They do not alone establish neuritis or safe discharge; hearing, neurological findings and the clinical course still matter.

Central-concern pattern: The original example describes spontaneous direction-changing or pure vertical nystagmus and inability to stand. Escalate urgently. Central-pattern nystagmus already justifies concern; HIT is not required before acting. These are teaching examples, not documented patient outcomes.

Medication and imaging pitfalls

Vestibular suppressants and sedatives can confound the examination. When feasible, examine first, document treatment already given and reassess limitations. Do not delay necessary symptom relief. Ondansetron should not be grouped with meclizine or diazepam as a vestibular suppressant. Medication effects.

A normal noncontrast CT does not exclude posterior-circulation ischemia. CT and vascular imaging still have roles in an acute stroke pathway; do not delay time-critical treatment decisions while waiting for MRI. Early diffusion-weighted MRI can also miss stroke. Persistent central concern despite a negative scan requires expert reassessment and, when indicated, further imaging. Primary AVS evidence.

Document findings, not a pre-filled diagnosis

Record: onset and timing; triggers and symptom-free intervals; neurological and hearing findings; spontaneous/positional nystagmus and direction; HIT indication, actual result and side; standing/gait and support needed; medications and technical limitations; working diagnosis and residual uncertainty; investigations, consultations, reassessment and disposition actually arranged.

Discharge requires a coherent diagnosis, safe mobility and function, an appropriate follow-up plan and explicit return precautions. New neurological symptoms, new hearing loss, worsening imbalance or an unexpected course should trigger reassessment. A technically limited or discordant examination is a reason to investigate further, not to label the result peripheral.