What is the initial approach to managing dizziness in adolescents?

Initial Approach to Managing Dizziness in Adolescents

The initial approach to managing dizziness in adolescents should focus on identifying the most common causes including migraine-related syndromes, psychiatric comorbidities, and benign paroxysmal vertigo, followed by targeted interventions based on the specific etiology. 1, 2

Assessment Framework

Step 1: Characterize the Dizziness

• Determine the specific type of dizziness:
  • Vertigo (spinning sensation)
  • Presyncope (feeling of fainting)
  • Dysequilibrium (unsteadiness)
  • Lightheadedness (vague sensation) 3

Step 2: Timing and Triggers Assessment

• Episodic vs. continuous symptoms
• Duration of episodes (seconds, minutes, hours, days)
• Specific triggers:
  • Position changes (suggestive of BPPV)
  • Visual stimuli
  • Stress or anxiety situations
  • Relationship to headaches (migraine-associated) 3, 2

Step 3: Focused Physical Examination

• Vital signs including orthostatic blood pressure
• Neurological examination including cranial nerves
• Otoscopic examination
• Assessment for nystagmus
• Dix-Hallpike maneuver for positional vertigo
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if indicated 3

Management Algorithm

For Migraine-Related Dizziness (Most Common in Adolescents)

1. Lifestyle modifications:

   • Regular sleep schedule
   • Adequate hydration
   • Avoidance of known triggers
   • Stress management techniques 1

2. First-line pharmacologic treatment:

   • Start with NSAIDs for acute episodes
   • Consider prophylactic treatment for frequent episodes 2

For Benign Paroxysmal Vertigo

1. Reassurance about benign nature
2. Canalith repositioning procedures (Epley maneuver) if appropriate 3
3. Vestibular rehabilitation exercises 3

For Psychiatric/Somatoform Dizziness

1. Screening for anxiety and depression using standardized tools
2. Cognitive-behavioral therapy approaches
3. Gradual exposure to anxiety-provoking situations
4. Consider psychiatric referral for moderate to severe cases 1, 2

For Vestibular Paroxysmia

• Consider low-dose carbamazepine as treatment 2

Follow-Up and Monitoring

• Schedule follow-up within 2-4 weeks for initial assessment
• Utilize standardized symptom tracking tools
• Establish clear criteria for specialty referral:
  • Persistent symptoms despite initial management
  • Red flags suggesting central causes
  • Significant functional impairment 1

Common Pitfalls to Avoid

• Failing to recognize migraine-related vertigo, which accounts for approximately 50% of dizziness cases in adolescents 2
• Over-reliance on vestibular suppressant medications, which can impede central compensation 3, 4
• Inadequate screening for psychiatric comorbidities, which are present in about half of adolescents with dizziness 2
• Missing the opportunity for early vestibular rehabilitation, which can significantly improve outcomes 3, 4

By following this structured approach, clinicians can effectively manage most cases of dizziness in adolescents while appropriately identifying those requiring specialty referral.