What is the appropriate workup for a teenager presenting with dizziness?

Workup for Dizziness in Teenagers

The appropriate workup for a teenager with dizziness should focus on identifying the timing, triggers, and associated symptoms, with initial evaluation including orthostatic vital signs, neurological examination, and vestibular testing, while reserving imaging for cases with abnormal neurological findings or concerning features. 1

Initial Assessment

History

• Timing patterns:

  • Brief episodes triggered by position changes (seconds) suggest BPPV
  • Prolonged episodes (hours to days) suggest vestibular neuritis or Menière's disease
  • Variable duration with headache history suggests vestibular migraine 1

• Triggers:

  • Position changes (BPPV)
  • Specific head movements
  • Relation to exercise or standing (orthostatic causes)
  • Association with headaches (migraine-associated vertigo) 1, 2

• Associated symptoms:

  • Hearing loss, tinnitus, aural fullness (Menière's disease)
  • Headache, photophobia, phonophobia (vestibular migraine)
  • Neurological deficits (central causes)
  • Palpitations, chest pain (cardiac causes) 1, 3

Physical Examination

1. Vital signs with orthostatic measurements
2. Neurological examination including cranial nerves
3. Vestibular assessment:
   • Nystagmus evaluation (spontaneous and gaze-evoked)
   • Dix-Hallpike maneuver for positional vertigo
   • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if acute vestibular syndrome present 1, 2
4. Cardiovascular examination including heart rate and rhythm 3

Diagnostic Testing

First-Line Testing

• No imaging is necessary for typical BPPV with positive Dix-Hallpike test 4, 1
• Laboratory testing is generally not required but consider:
  • Complete blood count if anemia suspected
  • Electrolytes, glucose if metabolic causes suspected
  • Thyroid function tests if thyroid dysfunction suspected 2

When to Consider Imaging

• MRI brain (preferred over CT) is indicated for:

  • Abnormal HINTS examination
  • Associated neurological deficits
  • Symptoms not responding to appropriate treatment
  • Atypical presentation or red flags 1

• CT head has limited utility in vertigo evaluation but may be used in emergency settings when MRI is unavailable 4, 1

Common Causes of Dizziness in Teenagers

1. Benign Paroxysmal Positional Vertigo (BPPV)

   • Most common cause of vertigo (42% of cases)
   • Diagnosed with Dix-Hallpike maneuver
   • Treated with canalith repositioning procedures (Epley maneuver) 1

2. Vestibular Migraine

   • Common in adolescents
   • Variable duration, history of migraine
   • Associated photophobia, mild or absent hearing loss 1, 5

3. Orthostatic Hypotension

   • Common in teenagers, especially females
   • Symptoms upon standing
   • Diagnosed with orthostatic vital signs 3

4. Post-Traumatic Vertigo

   • History of head trauma
   • Can manifest as BPPV or other vestibular symptoms 1

5. Anxiety-Related Dizziness

   • Common in adolescents
   • Often described as lightheadedness rather than true vertigo
   • Associated with hyperventilation or stress 3, 6

Red Flags Requiring Urgent Evaluation

• Sudden severe headache with dizziness
• New neurological symptoms
• Inability to walk or stand
• Persistent vomiting with dizziness
• Somnolence or altered mental status 1

Management Approach

1. For BPPV: Canalith repositioning procedures (Epley or Semont maneuvers) 1, 2

2. For Vestibular Migraine: Migraine-specific medications and prophylactic therapy for frequent episodes 1

3. For Vestibular Neuritis: Brief use of vestibular suppressants and vestibular rehabilitation 1

4. For Orthostatic Causes: Hydration, salt intake, compression stockings, and gradual position changes 3

5. For Anxiety-Related Dizziness: Reassurance, breathing techniques, and possible referral for cognitive behavioral therapy 6

Clinical Pearls

• Dizziness descriptions from patients are often vague and inconsistent; focus on timing and triggers rather than symptom quality 6
• The HINTS examination has superior sensitivity (100%) compared to early MRI (46%) for detecting stroke in acute vestibular syndrome 1
• Pharmacologic intervention should be limited as it may interfere with central compensation for vestibular disorders 2
• In teenagers, particularly females, dizziness is often benign but can cause significant distress and functional impairment 3