TiTrATE: how the dizzy patient is sorted

The framework’s central claim is that the question “what kind of dizziness is it” is the wrong first question, because patients describe the same sensation in different words and change their description when asked again. Timing and triggers are more stable, and they decide which examination is worth doing at all (Newman-Toker & Edlow, 2015 (TiTrATE)).

Three timing patterns are usually distinguished: acute and continuous, present at rest for days; episodic, coming in discrete attacks with well periods between; and chronic, persisting over months. Each carries a different differential and a different bedside examination.

The literature treats these as reasons to escalate rather than to continue a vestibular workup (Newman-Toker & Edlow, 2015 (TiTrATE); Kattah et al., 2009 (HINTS)):

• New neurologic signs: slurred speech, double vision, swallowing trouble, facial or limb weakness or numbness, limb incoordination
• Severe, new, or unusual headache, or recent head or neck trauma
• Cannot stand or walk unaided (truncal instability out of proportion)
• Nystagmus that is purely vertical, purely torsional, or changes direction with gaze

Continuous vertigo at rest sits apart from that list. It defines the acute vestibular syndrome; until a central cause has been excluded by someone equipped to do so, treat it as an escalation, not a rehab referral. That is NeuroDash’s rule, built on TiTrATE’s framing — the papers themselves treat it as the definition of the syndrome, not a stop feature.

Truncal instability is worth reading twice. A patient who cannot stand or walk unaided, out of proportion to what the rest of the exam suggests, is the finding most easily explained away and the one least safe to explain away.

This is the syndrome the HINTS battery was studied in: head impulse, nystagmus, test of skew, read together and never in isolation. A normal head impulse, direction-changing nystagmus, or a skew deviation each point away from the labyrinth (Kattah et al., 2009 (HINTS)).

The battery was validated in trained hands and in patients with acute, continuous symptoms and at least one vascular risk factor. It is examiner-dependent. A normal-looking impulse in an untrained hand is not the same finding as a normal impulse in the study.

Attacks lasting seconds to under a minute, triggered by a change in head position and settling in between, are the pattern of BPPV. The Dix-Hallpike and the supine head-roll are the tests that define it, and the diagnostic criteria are set out in the AAO-HNS guideline (AAO-HNS BPPV guideline (Bhattacharyya et al., 2017)).

Applying HINTS here is the framework’s most commonly named misuse. The battery is not validated outside acute continuous vertigo, and a positional syndrome is a different question with a different examination (Newman-Toker & Edlow, 2015 (TiTrATE)).

Reading these signs quickly is a skill, and it is what the rest of NeuroDash is for. The drill renders the eye movements from a kinematics engine and asks you to make the call, with the answer derived from the same parameters that drew the animation.