What is the management of vertigo (dizziness) in pediatric patients?

From the Guidelines

Managing dizziness in children requires a comprehensive approach that prioritizes identifying the underlying cause while providing supportive care, with a focus on ensuring the child's safety and alleviating symptoms to improve quality of life and reduce morbidity and mortality risks. The management of vertigo (dizziness) in pediatric patients involves a thorough evaluation to determine the underlying cause, which could range from benign paroxysmal positional vertigo (BPPV) to more serious conditions like vestibular migraine or labyrinthitis. According to the clinical practice guideline for BPPV 1, diagnosis should involve specific maneuvers like the Dix-Hallpike test for posterior semicircular canal BPPV and the supine roll test for lateral semicircular canal BPPV.

Key Considerations in Management

• Safety First: Ensure the child is in a safe position to prevent falls, which is crucial for preventing injuries and reducing morbidity.
• Hydration and Nutrition: Encourage adequate hydration and regular meals, as dehydration and low blood sugar can exacerbate dizziness symptoms and impact quality of life.
• Medication: For motion sickness-related dizziness, medications like dimenhydrinate (Dramamine) can be used at a dose of 1-1.5 mg/kg every 6-8 hours for children over 2 years old, or meclizine (Antivert) for older children at 12.5-25 mg every 6 hours as needed, but always considering the potential side effects and the risk-benefit ratio in terms of morbidity and mortality.
• Non-Pharmacological Approaches: Non-pharmacological methods such as having the child focus on a fixed point in the distance, providing fresh air, and avoiding reading or screen time during travel can be beneficial in managing dizziness and improving quality of life.
• Vestibular Rehabilitation: For vestibular-related dizziness, gradual exposure to triggering movements through vestibular rehabilitation exercises may help, and this approach is supported by the guideline on BPPV 1 as an option for treatment, which can help reduce morbidity and improve quality of life.

When to Seek Medical Attention

It's crucial to seek medical attention if dizziness is severe, persistent, accompanied by hearing loss, headaches, vision changes, or if it affects daily activities, as these could be signs of a more serious underlying condition that may impact morbidity and mortality. The inner ear contains fluid-filled canals that help maintain balance, and disruptions to this system can lead to the sensation of dizziness as the brain receives conflicting signals about the body's position and movement, highlighting the importance of prompt and appropriate management to prevent long-term effects on quality of life and to reduce morbidity and mortality risks.

Given the potential complexity of diagnosing and managing vertigo in pediatric patients, and considering the most recent and highest quality evidence available, the most appropriate management strategy should prioritize a thorough diagnostic evaluation followed by targeted treatment based on the underlying cause, with a focus on supportive care and safety to minimize morbidity and mortality risks and improve quality of life 1.

From the Research

Management of Vertigo in Pediatric Patients

The management of vertigo in pediatric patients involves a multifaceted approach, including diagnosis, treatment, and rehabilitation.

• Diagnosis is established through careful history taking, physical examination, and adjunctive tests such as vestibular testing and audiometry 2.
• Treatment options include vestibular rehabilitation, migraine hygiene, psychological therapies, pharmaceuticals, and/or surgery, which are tailored to the cause of vertigo 2.
• A study of 100 children treated at a pediatric vertigo center found that vestibular migraine was the most common diagnosis, followed by benign paroxysmal vertigo of childhood 3.
• Treatment approaches for pediatric vertigo include medical treatment, vestibular physiotherapy, and particle repositioning maneuvers, with some patients receiving multimodal treatment 3.

Treatment Options

Various medications can be used to manage vertigo in pediatric patients, including:

• Anticholinergics, antihistamines, benzodiazepines, calcium channel antagonists, and dopamine receptor antagonists 4.
• Aminopyridines for downbeat nystagmus and episodic ataxia type 2; carbamazepine for vestibular paroxysmia, paroxysmal dysarthria and ataxia in multiple sclerosis, and superior oblique myokymia 5.
• Betahistine, dexamethasone, and gentamicin for Menière's disease; gabapentin and memantine for different forms of acquired and congenital nystagmus 5.
• Metoprolol and topiramate for vestibular migraine; and selective serotonin reuptake inhibitors such as paroxetine for phobic postural vertigo 5.

Vestibular Migraine

Vestibular migraine is a common cause of vertigo in pediatric patients, and treatment options include:

• Explanation and reassurance, as many patients do not need pharmacological treatment 6.
• Acute attacks can be ameliorated with antiemetic drugs such as diphenhydramine, meclizine, and metoclopramide 6.
• Frequent attacks may warrant pharmacological prophylaxis with metoprolol, amitriptyline, topiramate, valproic acid, or flunarizine 6.
• Nonpharmacological measures including regular exercise, relaxation techniques, stress management, and biofeedback may be similarly effective and can be combined with a pharmacological approach 6.