TiTrATE also gives a quick overview of less urgent and more urgent differential diagnoses in one of the three syndromes (e.g., episodic vestibular syndrome, triggered: this might include BPPV (less urgent) or central positioning nystagmus due to a posterior fossa tumor (more urgent)). For example, benign paroxysmal positional vertigo (BPPV) is an episodic vestibular syndrome triggered by head motion, while, Menière’s disease is an episodic vestibular syndrome without any trigger. These syndromes can be subdivided into triggered or untriggered syndromes. Focusing on the time course enables symptoms to be categorized into three major syndromes: acute vestibular syndrome, episodic vestibular syndrome, and chronic vestibular syndrome ( Table 1). This was why the TiTrATE (timing, triggers and targeted examination) paradigm was proposed, to emphasize the importance of the time course and triggers of symptoms in history taking. Unfortunately, this approach has proved unreliable, for a variety of reasons: terms like ‘vertigo’ and ‘dizziness’ have different meanings to different people and in different languages patients often have problems defining their symptoms symptom descriptions might change over time and the quality of the symptoms has little discriminative value. The traditional, widespread approach in history taking is to focus on the quality of the symptoms, e.g., vertigo, presyncope, disequilibrium, or non-specific dizziness. In addition, pearls and pitfalls will be discussed separately for each step. The four steps are: (1) describing any attack(s) of vertigo and/or dizziness (2) describing any chronic vestibular symptoms (3) screening for functional, psychological, and psychiatric co-morbidity (4) establishing a comprehensive diagnosis, including all possible co-occurring (vestibular) disorders.
It involves a systematic approach that explicitly identifies all co-occurring vestibular disorders in the same patient, and which addresses each of these vestibular disorders separately. The aim of this document is to describe a 4-step approach for improving history taking in patients with non-acute vestibular symptoms, by guiding the clinician and the patient through the history taking process. History taking can, therefore, be improved by addressing the important aspects of each co-occurring vestibular disorder separately. This complicates history taking, since the time course, triggers, and accompanying symptoms can vary, depending on the disorder. However, multiple (vestibular) disorders may co-occur in the same patient. time course, triggers, and accompanying symptoms. To facilitate the process, systems such as TiTrATE, SO STONED, and DISCOHAT have been used to describe the different paradigms together, they address the most important aspects of history taking, viz. History taking is crucial in the diagnostic process for vestibular disorders.