TiTrATE your approach to vertigo

Neurology Clinics ran an issue dedicated to the assessment of acute vertigo. Out of this issue (don't you read them all avidly?) two articles caught my eye...

The TiTrATE Approach

David Newman-Toker of HINTS fame and Jonathan Edlow put forward TiTRATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. The TiTrATE approach stands for timing, triggers and targeted examination.


In this article, they argue that a good history focused on symptom timing and triggers will narrow down the potential diagnoses, allowing a targeted examination to complete the diagnosis.



Using this structure, they identify 4 vestibular syndromes that are differentiated further on targeted examination:

  • Triggered episodic vestibular syndrome (eg BPPV, orthostatic hypotension)
  • Spontaneous episodic vestibular syndrome (eg Menière's, vasovagal, panic)
  • Traumatic/toxic acute vestibular syndrome (eg vertebral artery dissection, barotrauma, toxins)
  • Spontaneous acute vestibular syndrome (eg central cause)
The TiTrATE algorithm, colour coded for risk of dangerous disorder


The article contains a lot of useful differentiating information and techniques that will aid your assessment of dizziness and vertigo. They conclude:

A majority of cases with initial diagnostic uncertainty are due to common cardiovascular (medication-induced orthostatic hypotension and vasovagal syncope), psychiatric (panic disorder), or vestibular (BPPV, vestibular migraine, and vestibular neuritis) disorders. These benign conditions can each be diagnosed confidently at the bedside using a syndrome-targeted history and examination. Patients whose presentations are atypical or whose targeted examination findings are suspicious for dangerous underlying causes should undergo appropriate laboratory tests, imaging, or consultation.


Bedside Assessment of Dizziness and Vertigo

This article provides a slightly different approach to the history and examination, capturing many of the same information. Best of all, they include illustrations!



After an open-ended history, they recommend addressing a few key questions:

  1. Is it truly vertigo?
  2. Is it the first ever attack or is it long-standing recurrent vertigo?
  3. Is it spontaneous or positional?
  4. What is the duration of each spell?
  5. What are the associated symptoms?
  6. Do recent events provide a clue (such as trauma, new medications)?

They then move on to physical examination, looking for:

  1. General inspection - head tilt, ocular tilt reflex, Horner syndrome
  2. Spontaneous and gaze-evoked nystagmus
  3. Provocative testing for nystagmus (eg Dix-Hallpike)
    Anyone use Frenzel goggles?
    Anyone use Frenzel goggles?
  4. Head impulse
  5. Oculomotor examination
  6. Vestibulospinal reflexes
  7. General neurologic assessment
  8. Postural BP, pulse, auscultation


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