Work it through
Approach & the team
Two things make vertigo manageable: a framework that sorts any presentation at the front door, and a team that knows who does what afterwards.
The framework — timing, triggers, targeted exam
Rather than asking “what does the dizziness feel like?” (unreliable), the TiTrATE approach asks about timing and triggers, which sort the patient into one of four vestibular syndromes, then applies a targeted examination to confirm the cause.1
| Syndrome | Timing | Typical causes |
|---|---|---|
| Acute vestibular syndrome | Acute, continuous vertigo > 24 h | Vestibular neuritis vs posterior-circulation stroke — separated by HINTS |
| Triggered episodic | Brief, recurrent, provoked by position or standing | BPPV (positional) · orthostatic hypotension (on standing) |
| Spontaneous episodic | Recurrent spells without a clear trigger | Vestibular migraine · Ménière's disease · vertebrobasilar TIA |
| Chronic vestibular syndrome | Persistent dizziness/imbalance over months | PPPD · bilateral vestibulopathy · presbyvestibulopathy · MdDS |
The single highest-value targeted examination is HINTS in the acute vestibular syndrome — more sensitive than early MRI for stroke when applied correctly.2,3 Match the examination to the syndrome: positional testing for triggered-episodic, audiometry for spontaneous-episodic with cochlear features, and gait/visual-dependence assessment for the chronic syndromes.
The multidisciplinary team
Vertigo crosses specialty boundaries, and the best outcomes come from coordinated care. Select a role to see what each discipline contributes — these are the hand-offs the cases put into practice.
Emergency medicine
Triages the acute dizzy patient, applies HINTS in acute vestibular syndrome, and activates the stroke pathway when central features appear.
Key points
- Ask about timing and triggers, not what the dizziness “feels like.”
- Four syndromes: acute, triggered-episodic, spontaneous-episodic, chronic.
- Match the targeted exam to the syndrome — HINTS for acute vestibular syndrome.
- No single specialty owns vertigo; coordinated hand-offs drive outcomes.