🌀Dizziness and Vertigo 🌀

A top reason for ED visits, and a diagnostic nightmare.

Up to 35% of posterior circulation strokes are initially misdiagnosed as benign vertigo.

The key isn’t asking what it feels like. It’s asking when and why it happens.

Here’s a better framework.

🧵

The Framework: TiTrATE

Stop asking the unreliable “Is it spinning or are you lightheaded?” question. Patients use these terms interchangeably.

A more robust approach is the TiTrATE framework:
• Timing
• Triggers
• And
• Targeted Examination

This shifts the focus from symptom quality to clinical context.

1. TIMING: Is it continuous or episodic?

This is the first branch point.

• Acute Vestibular Syndrome (AVS): Continuous, unrelenting dizziness lasting days to weeks. The key differential is vestibular neuritis vs. posterior circulation stroke.

• Episodic Vestibular Syndrome (EVS): Recurrent, transient attacks of dizziness.

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2. TRIGGERS: What brings it on?

For episodic dizziness (EVS), the next question is about triggers.

• Triggered by position changes (e.g., rolling in bed, looking up): Think BPPV or orthostatic hypotension.

• Spontaneous (occurs at rest, without a trigger): Think vestibular migraine, Meniere’s disease, or a TIA.

3. Targeted Exam: The HINTS Exam for AVS

For the AVS patient (continuous dizziness), the HINTS exam is more sensitive than an early MRI for stroke.

Remember INFARCT for central signs:
• Impulse Normal
• Fast-phase Alternating Nystagmus
• Refixation on Cover Test (Skew)

A normal Head Impulse is the most concerning finding.

4. Targeted Exam: Triggered Dizziness

For triggered episodic dizziness, two simple maneuvers are key.

• Dix-Hallpike Maneuver: This is diagnostic for posterior canal BPPV. Look for the classic latency followed by transient, upbeat-torsional nystagmus.

• Orthostatic Vitals: A drop in SBP ≥20 or DBP ≥10 is diagnostic for orthostatic hypotension.

5. Red Flags: The 5 D’s

The presence of any of these associated symptoms should immediately raise your suspicion for a central (brainstem/cerebellar) cause.

• Diplopia
• Dysarthria
• Dysphagia
• Dysmetria
• Dysphonia

The biggest red flag of all? Inability to walk unassisted. If they can’t walk, think cerebellum.

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Key Treatment Pearls

Treatment is diagnosis-specific, but two pearls stand out:

• BPPV: Treat with canalith repositioning maneuvers (e.g., Epley). Vestibular suppressants like meclizine are not indicated and can delay recovery.

• Vestibular Neuritis: Vestibular suppressants should be used for <72 hours ONLY. Prolonged use impairs the brain’s ability to compensate.

Summary

Stop relying on subjective dizziness descriptors. A systematic approach using Timing, Triggers, & a Targeted Exam (TiTrATE) is far more reliable.

This framework helps you confidently diagnose benign causes like BPPV and, critically, identify the dangerous mimics like stroke.