Vertigo Sorter
Sort the dizzy patient by timing and triggers (the TiTrATE approach), then do the matching bedside tests.
Red flags: send to emergency
- New severe or sudden headache, or neck pain (think dissection)
- Any new neuro sign: double vision, slurred speech, trouble swallowing, facial or limb weakness or numbness, limb ataxia
- Can’t walk or stand unaided (truncal ataxia)
- Sudden hearing loss, especially with vertigo
- Continuous vertigo in someone with vascular risk factors, or central signs on HINTS
HINTS exam in brief
- Only for continuous vertigo (acute vestibular syndrome) with nystagmus present at the time of the exam. Not for episodic or positional dizziness.
- Head impulse: a corrective catch-up saccade is reassuring (peripheral). A normal head impulse in an acutely vertiginous patient is worrying (central).
- Nystagmus: one direction, horizontal, dampened by fixation is peripheral. Direction-changing on gaze, vertical or purely torsional is central.
- Test of skew: alternate cover test. Any vertical refixation is central.
- Any one central finding means stroke until proven otherwise. Adding new hearing loss (“HINTS plus”) raises sensitivity.
- Highly accurate in trained hands, but it needs training and practice. If unsure, refer.
- Early CT misses most posterior fossa strokes, and even early MRI can be falsely negative.
Positional tests and manoeuvres
- Dix-Hallpike (posterior canal): brief delay, then up-beating torsional nystagmus towards the lower ear, fading within a minute. Treat with the Epley manoeuvre on the affected side.
- Supine roll test (horizontal canal): do it if the Dix-Hallpike is negative but the story fits. Horizontal nystagmus on turning either way. Treat with the barbecue (Lempert) roll or Gufoni manoeuvre.
- Repeat the manoeuvre if symptoms persist. Atypical nystagmus or failure after a few goes means reconsider the diagnosis.
- Vestibular physiotherapy helps recurrent or residual symptoms.
For clinicians, education only. A teaching aid, not a diagnosis. It doesn’t replace clinical judgement or local stroke pathways.
Sources
- Rogers TS et al. Dizziness: evaluation and management. Am Fam Physician 2023;107(5):514-523
- Newman-Toker DE, Edlow JA. TiTrATE: a novel approach to diagnosing acute dizziness and vertigo. Neurol Clin 2015
- Bhattacharyya N et al. Clinical practice guideline: BPPV (update). Otolaryngol Head Neck Surg 2017
- Kattah JC et al. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke 2009