A Clinician’s Guide to Dizziness: the Triage-TiTrATE Model

Introduction

Dizziness is a common complaint among patients seeking care. The dizzy patient is frequently seen in a primary care setting and emergency department visits, accounting for up to 5% of those types of encounters.1,2 Over their lifespan, close to 35% of the adult population can present to a health care provider for a complaint of dizziness.2 Moreover, up to 25% of patients with dizziness have a potentially life-threatening condition (eg, stroke, cardiovascular, or metabolic events), and nearly 50% of patients can leave the clinician with an incorrect diagnosis or no official diagnosis at all.2,3  

Because of the extensive overlapping etiologies of dizziness, it is prudent to have a well-rounded and universal approach.4 Classically, the subjective and ambiguous definition of dizziness is divided into 4 major descriptive categories or types5:

• Vertigo (the illusion of spinning)
• Presyncope (feeling of impending faint)
• Disequilibrium (unsteadiness when walking)
• Non-specific/ill-defined (lightheaded, giddy, woozy)

However, patient descriptions may be vague and vary considerably (eg, vertigo, spacey, rocking, weak, lightheaded, brain fog, floating, or off-balance), while some are unable to truly describe their sensations.6 This traditional approach based on type of dizziness has never been validated, is unreliable because it is not evidence-based, and has not been shown to accurately correlate with the cause of dizziness.7-9 Ultimately, with prevention of morbidity and mortality in mind, providers can take a better approach. 

The Triage-TiTrATE method may serve as a useful model for isolating the potential causes of dizziness.10-12 This method shifts the focus toward triaging, with an emphasis on symptom timing and triggers, while using targeted bedside eye exams. In brief, an initial triage to identify obvious threats or causes coupled with a dizziness classification into a respective vestibular syndrome is based on the patient’s history of timing and triggers. This may help reduce complexity and decrease the rate of misdiagnosis, particularly from a serious cause. This method is supported by a current best-evidence approach to dizziness.13 Of note, a 2020 study using an algorithm sequence questionnaire based on timing and triggers was shown to be both valid and reliable in helping predict the most likely cause of dizziness in an outpatient setting.14

Taking a History

When a patient presents with dizziness it is important to take a thorough history. Patient descriptions can offer benefits, however mostly lack utility in diagnosis given the variety of subjective symptoms that can be described.15 History components should outline the dizziness onset (new or recurrent), duration, triggers, and associated symptoms versus identifying the type of dizziness.10 Reviewing the past medical history, family medical history, social history, and medications will offer hints into a diagnosis. Gathering the appropriate information will also help uncover a peripheral versus central cause of dizziness, such as a stroke.16 

Triage

Recognize dangerous and/or nonvestibular causes based on history, vital signs, and selective testing.17  

Examples:

• History: dangerous D’s (diplopia, dysarthria, dysphonia, dysphagia, dysmetria), thunderclap headache, head-neck-ear injury, photophobia, chest pain, presyncope, shortness of breath (SOB), pleurisy, vomiting, diarrhea, melena, vaginal bleeding in pregnancy, medications (new or altered dose), drug or alcohol ingestion, bleeding, anxiety.18
• Vital signs: hypothermic, hyperthermic, bradycardia, tachycardic, hypotensive, hypertensive, hypoxic.
• Testing: patient-specific, and may include: blood glucose, complete blood count, complete metabolic panel, electrocardiogram, cardiac enzymes, chest radiograph, D-dimer, and urine drug screen.

Timing (TiTrATE)

During this step, the provider discovers the onset, duration, and evolution of the dizziness. It is then categorized as an acute, episodic, or chronic vestibular syndrome.10

• Acute: new-onset episode, persistent, and prolonged for days to weeks.
• Episodic: recurrent intermittent dizziness for seconds, minutes, or hours, classified as either triggered or spontaneous.
• Chronic: lasting weeks, months, or years.

Triggers (TiTRATE)

Information about what triggers dizziness can help the provider discern whether it is provoked by an event or exposure.12

• Head or body movement, standing, visual, sounds, Valsalva.19

And Targeted Exams (TiTRATE)

Specific findings from a targeted eye examination can help separate benign from serious causes.11

• HINTS (head impulse, nystagmus, test of skew).
  • A clinically concerning HINTS exam that meets central criteria is shown to be 100% sensitive and 96% specific for stroke.20 
• Dix-Hallpike maneuver.

Types of Vestibular Syndromes

By using the timing and triggers history, providers can categorize the patient into a vestibular syndrome, and each syndrome will guide the targeted eye exam.22

Acute Vestibular Syndrome 

Acute vestibular syndrome (AVS) is defined as a new-onset episode of continuous and persistent dizziness lasting days to weeks. Associated symptoms may vary and include exacerbation with any head movement, nystagmus, unilateral hearing loss, abnormal gait, nausea, and vomiting.12  

It is important to differentiate between worsening symptoms with head movement and triggering of symptoms with head movement, as the former should fall under AVS.27 Common diagnoses to consider include posterior circulation ischemic stroke, vestibular neuritis (VN), and labyrinthitis. Less commonly seen are thiamine deficiency, medication toxicity, and multiple sclerosis.22 Caution is advised as even though stroke and VN are the most commonly seen, the potential for symptom overlap and similarities does exist, along with isolated dizziness in a stroke.28 

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History components should outline the dizziness onset (new or recurrent), duration, triggers, and associated symptoms versus identifying the type of dizziness…Gathering the appropriate information will help uncover a peripheral versus central cause of dizziness (ie, stroke).

A 3-step bedside eye movement exam known as the HINTS exam can confidently rule out stroke more precisely than magnetic resonance imaging (MRI) within the first 48 hours.29 HINTS is both cost-effective and time-saving.30 If imaging is deemed necessary, MRI is more sensitive and accurate for stroke detection than computed tomography (CT); however,  no accompanying diagnostic improvement is seen.31 Alternatively, the addition of a hearing exam to detect hearing loss (known as the HINTS PLUS exam) may aid in identifying brainstem ischemia.32 Finally, the use of video-oculography can also assist in stroke diagnosis.33

Episodic Vestibular Syndrome

Episodic vestibular syndrome (EVS) is defined as recurrent episodic bouts of intermittent dizziness lasting a few seconds, minutes, or hours. Multiple episodes are typically experienced by the patient. The condition is divided into subcategories of triggered or spontaneous. 

Triggered: dizziness that is triggered by a specific event or exposure, with episodes typically lasting less than 1 minute. Most commonly caused by a change in head position or standing, such as benign paroxysmal positional vertigo (BPPV) and orthostatic hypotension.10,12 Other causes include postural orthostatic tachycardia syndrome (POTS) and superior semicircular canal dehiscence syndrome (SCDS), which are less common.18

Spontaneous: dizziness that is not triggered by an apparent specific event or exposure. Conditions can include transient ischemic attack (TIA), vestibular migraine, Meniere’s disease, and panic attack/hyperventilation.21 Episodes will typically last minutes to hours. 

Chronic Vestibular Syndrome

Chronic vestibular syndrome (CVS) is defined as dizziness that lasts weeks, months, or years, and that may or may not have an initial or discernible cause. The differential diagnosis can include acoustic neuroma, posterior fossa tumor, cerebellar disease, multiple sclerosis, somatoform or psychogenic, post-concussive syndrome, and polypharmacy.12,23,24,26 Rare causes of CVS are bilateral vestibular loss (BVL) and persistent postural-perceptual dizziness (PPPD).18,25 

Additional Neurologic Testing, Imaging, and Labs

Considering the complexity of diagnosing the dizzy patient, the practitioner must personalize additional neurologic tests, neuroimaging, and laboratory testing based on the history and examination. Clinically relevant physical exam testing may include pronator drift, rapid alternating movements, finger-to-nose, gait analysis, Romberg, and the Timed Up and Go.

Key Clinical Points

1. Dizziness can present as the sole symptom of a stroke.
2. As the HINTS exam and Dix-Hallpike maneuver have strong reliability, the provider should learn to effectively and correctly perform them.
3. Movement may exacerbate symptoms in ANY vestibular syndrome; do not take this as a positive Dix-Hallpike in error.
4. If a HINTS exam displays even 1 central sign, this should point towards a concerning cause.
5. The targeted eye exam is more sensitive than MRI in patients presenting in the first 48 hours.
6. CT is a poor test to exclude posterior circulation stroke.
7. Each vestibular syndrome closely relates to a specific differential diagnosis list.

Conclusion

Identifying the etiology of dizziness is complex, and without a methodical approach, providers risk missing the correct diagnosis. The Triage-TiTrATE method provides a credible approach. Accurately triaging and emphasizing key features of the complaint, in combination with a targeted bedside eye exam, will likely have better patient outcomes than traditional methods incorporating subjective descriptions of dizziness. Clinically appropriate testing and management can then ensue. Further research should aim to confirm this algorithm’s accuracy and effect on clinical practice. 

For instructional videos on HINTS and Dix-Hallpike, please see:

https://www.medmastery.com/magazine/vertigo-maneuversperforming-hints-exam

This article originally appeared on Clinical Advisor