← GPCalc

Dizziness Assessment Tool

TiTrATE approach · NICE CKS vertigo, BPPV, vestibular neuronitis and Ménière's · NICE NG128, CG109, NG98 · DVLA

Patient

What do they mean by "dizzy"?

Red flags

Associated features

Targeted examination

Enter lying and standing BP to check for orthostatic hypotension.

NICE-recommended plan

Choose what the person means by 'dizzy' and the timing pattern to see the plan.

Decision support only, based on NICE CKS, NICE NG128, CG109 and NG98, DVLA guidance and the TiTrATE framework. HINTS testing is only reliable in people with continuous vertigo and nystagmus, done by a trained clinician – if in doubt, treat as a possible stroke. It does not replace clinical assessment.

Quick reference

TiTrATE – timing and triggers
PatternCommon causesDangerous mimics
Triggered, brief (head position)BPPVCentral positional vertigo
Triggered on standingOrthostatic hypotension, medicinesArrhythmia, haemorrhage
Spontaneous episodes, minutes–hoursVestibular migraine, Ménière's, panicTIA, arrhythmia
Acute continuous, daysVestibular neuronitis, labyrinthitisPosterior circulation stroke
Chronic over 3 monthsPPPD, medicines, multifactorial imbalanceVestibular schwannoma, cerebellar disease
HINTS (acute continuous vertigo with nystagmus)
  • Head impulse: abnormal (corrective saccade) = peripheral; normal = worrying.
  • Nystagmus: unidirectional horizontal = peripheral; direction-changing, vertical or torsional = central.
  • Test of skew: vertical refixation on cover test = central.
  • Any central sign, inability to walk, new hearing loss with vertigo, or doubt → same-day stroke assessment.
Referral timings
  • Suspected stroke: 999. Suspected TIA: aspirin 300 mg, specialist within 24 hours (NG128).
  • Sudden hearing loss within 30 days: ENT or ED within 24 hours; over 30 days: within 2 weeks (NG98).
  • Blackout with red flags: cardiovascular assessment within 24 hours (CG109).
  • Vestibular neuronitis not improving at 1 week or unresolved at 6 weeks; BPPV not responding to repositioning; suspected Ménière's; unilateral hearing loss or tinnitus: ENT or audiovestibular medicine.