Neurological Causes of Head Bobbing Sensation
The sensation of head bobbing is most commonly associated with a rare condition called spasmus nutans, characterized by a triad of nystagmus, head bobbing, and torticollis, which requires thorough neuro-ophthalmological evaluation and MRI to rule out serious underlying causes such as anterior visual pathway tumors. 1
Central vs. Peripheral Causes
Central Causes
- Spasmus nutans typically appears between 1-3 years of age and resolves by 5-12 years, but requires MRI evaluation as it can mimic nystagmus associated with more serious conditions 1
- Bobble-head doll syndrome, a rare movement disorder characterized by involuntary 2-3 Hz head movements, is associated with third ventricular tumors, suprasellar arachnoid cysts, and aqueductal stenosis 2, 3
- Posterior circulation infarcts involving the brainstem or cerebellum can present with vertigo and associated head movement sensations, with a prevalence of cerebrovascular disease in patients with acute vestibular syndrome being approximately 25% 1, 4
- Multiple sclerosis involving the brainstem or cerebellar peduncles can cause acute vestibular syndrome with associated head movement sensations 1
Peripheral Causes
- Vestibular neuritis and labyrinthitis are common peripheral causes of vertigo that may present with sensations of head movement 1
- Benign paroxysmal positional vertigo (BPPV) can cause positional vertigo with associated head movement sensations, typically triggered by specific head positions 1
- Vestibular migraine has a prevalence of 3.2% and may represent up to 14% of vertigo cases, potentially causing sensations of head movement 5
Diagnostic Approach
Clinical Evaluation
- Assess whether the head bobbing sensation is:
- Provoked by positional changes (suggesting BPPV) 1
- Associated with nystagmus patterns (direction-changing nystagmus without head position changes suggests central cause) 5
- Accompanied by other neurological symptoms (focal deficits suggest central pathology) 1
- Persistent or episodic (persistent symptoms may indicate more serious pathology) 1
Neuroimaging
- MRI of the brain is the preferred imaging modality for evaluating head bobbing sensations, particularly when:
- CT imaging has limited utility in evaluating head bobbing sensations, with very low detection rates of contributory central nervous system pathology in patients with normal neurological examinations 1
Special Considerations
Rhythmic Movement Disorders
- Headbanging, a rhythmic movement disorder typically occurring during pre-sleep drowsiness or early non-REM sleep, can cause sensations of head bobbing 6
- These movements usually begin around 9 months of age and resolve by 10 years, but can persist into adulthood 6
- When persistent, they may respond to treatment with clonazepam 6
Pediatric Presentations
- In children, head bobbing may be associated with:
Management Implications
- Prompt diagnosis and treatment are essential, as delay can cause permanent neurological dysfunction and psychomotor retardation in cases like bobble-head doll syndrome 2
- Surgical interventions such as ventriculocystocisternostomy or ventriculo-peritoneal shunting may be required for structural causes of head bobbing 2, 7
- For rhythmic movement disorders like headbanging, clonazepam may be effective 6
- For vestibular causes, appropriate treatment depends on the specific diagnosis (repositioning maneuvers for BPPV, migraine prophylaxis for vestibular migraine) 5