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Recognizing the red flags of vertigo

Vertigo is the moving sensation of the head, body, or space around (turning or other movements) in a still position. Positional vertigo results from a distortion of the sense of movement following the head's motion in a still position. Doctors must be able to distinguish vertigo from other dizziness, such as "lightheadedness" at presyncope, or "feeling unbalanced on standing" in postural disorders.

The most common etiologies of peripheral vertigo is benign paroxysmal positional vertigo (BPPV). Meanwhile, central vertigo with the highest prevalence is vestibular migraine.

Other etiologies of peripheral vertigo are Meniere's disease, labyrinthitis, vestibular neuritis, Ramsay Hunt syndrome, and cholesteatoma. In comparison, other etiologies of central vertigo are stroke in the cerebellar area or vertebrobasilar system, cerebellopontine tumors, multiple sclerosis, substance intoxication.

Red Flags Vertigo
Some of the etiology of vertigo is mild, but some vertigo occurs in dangerous or life-threatening diseases. The doctor must be able to recognize vertigo red flags or the danger signs of vertigo as follows:
  1. Vertigo that is persistent and continues to get worse
  2. Sudden unilateral hearing loss with the first onset
  3. The patient complains of a sensation of vertical movement.
  4. Severe headaches, especially in the morning
  5. Focal neurological deficits such as diplopia, dysarthria, dysphagia, paresis, or paraesthesia of the extremities
  6. Ataxia or other symptoms of cerebellar disorders
  7. Papilledema
  8. The results of the HINTS examination include a normal head-impulse test, fluctuating direction of nystagmus (bidirectional), and a test of skew with a vertical deviation plus an abnormal hearing function test with new-onset, leading to vertigo due to central lesions.



The following important points should be asked during history to help differentiate the etiology of vertigo:
  1. Describe the complaints of "dizziness" clearly to distinguish vertigo from other dizziness. Patients often describe dizziness as a spinning sensation such as riding a carousel; the room feels spinning, the head is light as if it is about to faint, the feeling of being unbalanced is like going to fall sense of being swayed like on a boat.
  2. Find out what triggers a complaint, such as when changing head position or when still position.
  3. The timing of the event includes the onset, frequency, and duration of vertigo
  4. Comorbid diseases of patients and their families
  5. as well as routine medication consumed by patients.

The Dix-Halpike examination is preferable for patients with vertigo duration <2 minutes and no nystagmus at rest. Head impulse, nystagmus, a test of skew (HINTS) plus (plus hearing function tests) can be performed for patients who have complaints of vertigo with a duration of several hours or days, and if resting nystagmus or spontaneous nystagmus is found.

If the four HINTS test results plus the results are peripheral, the patient may have vestibular neuritis. However, imaging studies to exclude the central lesion should be performed if any of the HINTS plus results point to a central lesion. The HINTS plus examination is sensitive enough to detect vertigo due to central lesions, even if done within 48 hours of symptom onset.

Routine imaging exams are not recommended for all vertigo cases. However, the presence of red flags should raise the suspicion that the etiology is not a peripheral lesion but a central lesion. Imaging in the form of MRI (better) or CT-scan to detect the central lesion is needed if red flags are found on clinical examination.

Overview of Vertigo Management
Benign paroxysmal positional vertigo (BPPV) is a vertigo type diagnosed clinically and administered in a first-level health facility. However, vertigo with red flags, such as vertigo due to stroke, can be life-threatening, requiring immediate medical referral and follow-up treatment.

The following is a summary of management that can be done for vertigo patients:
  1. BPPV: Epley maneuver
  2. Vestibular neuritis: improves gradually with rest, medical in the form of short-term vestibular suppressants (antihistamines, antiemetics, benzodiazepines), vestibular rehabilitation
  3. Meniere's disease: a diet low in salt and caffeine, symptomatic medicine, hearing aids, vestibular rehabilitation
  4. Vestibular migraine: migraine management, vestibular suppressants, vestibular rehabilitation
  5. Stroke: refer a neurologist, and perform stroke management
  6. Other central vertigo: refer for etiologic management
  7. Information and Education Communication (IEC) for patients is useful for reducing anxiety
  8. Refer the patient to an otolaryngologist if accompanied by 

  • hearing loss, 
  • abnormal otoscopic examination results, 
  • and recurrent or persistent vertigo symptoms with characteristics of peripheral vestibular disorders.

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