What is the recommended evaluation and management for dizziness in a 9-year-old child?

Evaluation and Management of Dizziness in a 9-Year-Old Child

Begin by categorizing the dizziness based on timing and triggers—not the child's vague description—to determine if this represents brief episodic vertigo (seconds to minutes, positionally triggered), acute persistent vertigo (days to weeks of constant symptoms), spontaneous episodic vertigo (recurrent attacks without positional triggers), or chronic vestibular syndrome. 1

Initial History: Critical Details to Elicit

Focus your history on these specific elements rather than accepting vague descriptions of "dizziness":

• Duration of episodes: Seconds suggest benign paroxysmal positional vertigo (BPPV); minutes to hours suggest vestibular migraine; days to weeks suggest vestibular neuritis or central pathology 2, 1
• Triggers: Head position changes point to BPPV; no clear trigger suggests vestibular migraine or Ménière's disease 2
• Associated symptoms:
  • Headache, photophobia, phonophobia strongly suggest vestibular migraine 1, 2
  • Hearing loss, tinnitus, or aural fullness suggest Ménière's disease 2
  • Fever and otalgia suggest infectious labyrinthitis 2
• Migraine history: Vestibular migraine is the most common cause of dizziness in childhood 3

Physical Examination: Essential Components

Perform these specific maneuvers rather than a generic "comprehensive exam":

• Dix-Hallpike maneuver: Mandatory for any child with positionally-triggered symptoms to diagnose BPPV 2, 1
• Neurologic examination: Look specifically for focal deficits (diplopia, dysarthria, facial numbness, limb weakness) that indicate central pathology 4, 2
• Otoscopic examination: Rule out serous otitis media, a common cause in children 5
• Nystagmus assessment: Downbeating nystagmus or direction-changing nystagmus without head position change indicates central pathology 2, 4
• Gait and balance testing: Inability to stand or walk independently is a red flag requiring urgent evaluation 4

Diagnostic Algorithm by Clinical Presentation

If Brief Episodic Vertigo (Seconds, Positionally Triggered):

• Perform Dix-Hallpike maneuver immediately 2, 1
• If positive with typical torsional upbeating nystagmus: Diagnose BPPV and treat with Epley maneuver 1, 6
• No imaging is indicated for typical BPPV 1

If Spontaneous Episodic Vertigo (Minutes to Hours, No Positional Trigger):

• Vestibular migraine is most likely, especially if the child has headache, photophobia, phonophobia, or family history of migraine 2, 3
• Diagnostic criteria require ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, with migraine features in ≥50% of episodes 2, 7
• No imaging needed if neurologic exam is normal 1
• Treatment: Migraine prophylaxis and lifestyle modifications 1

If Acute Persistent Vertigo (Days to Weeks of Constant Symptoms):

This carries the highest stroke risk and requires careful differentiation 4:

• Perform full neurologic examination looking for focal deficits 4
• If neurologic exam is abnormal OR child has vascular risk factors: Obtain MRI brain without contrast immediately 1
• If exam is normal and symptoms suggest peripheral cause (vestibular neuritis): Consider conservative management with vestibular rehabilitation 6

Red Flags Requiring Urgent Evaluation and Imaging

Any of these findings mandate immediate MRI brain without contrast and neurology consultation: 4

• Focal neurological deficits (diplopia, dysarthria, facial numbness, limb weakness) 4
• Inability to stand or walk independently 4
• New severe headache accompanying dizziness 4
• Sudden unilateral hearing loss with vertigo 4
• Downbeating nystagmus or other central nystagmus patterns 4
• Loss of consciousness (never occurs with peripheral vestibular disorders) 4

Critical pitfall: 75-80% of children with posterior circulation stroke present with NO focal neurologic deficits on standard examination, so maintain high suspicion in acute persistent vertigo 4, 7

Imaging Decisions

Do NOT order imaging for:

• Brief episodic vertigo with typical BPPV features on Dix-Hallpike 1
• Spontaneous episodic vertigo consistent with vestibular migraine and normal neurologic exam 1
• Acute persistent vertigo with normal neurologic exam and clear peripheral features 1

Order MRI brain without contrast (NOT CT) for:

• Any red flag symptoms listed above 1, 4
• Unilateral or pulsatile tinnitus 4
• Failure to respond to appropriate vestibular treatments 4
• Atypical presentation that doesn't fit clear peripheral pattern 1

CT head has extremely poor sensitivity (20-40%) for posterior circulation pathology and should NOT be used instead of MRI when stroke is suspected 4, 7

Common Pediatric-Specific Considerations

• Serous otitis media is a common cause of dizziness in children that may be missed without otoscopic examination 5
• Benign paroxysmal vertigo of childhood presents with brief episodes that resolve spontaneously and is a diagnosis of exclusion 5
• Vestibular dysfunction is commonly seen in children with sensorineural hearing loss 3
• Children may have difficulty articulating symptoms, so rely more heavily on timing, triggers, and objective findings than subjective descriptions 1, 8

Treatment Based on Diagnosis

• BPPV: Canalith repositioning procedures (Epley maneuver) are first-line; no medication needed 1, 6
• Vestibular migraine: Migraine prophylaxis and lifestyle modifications 1
• Vestibular neuritis: Vestibular rehabilitation exercises 6
• Avoid chronic vestibular suppressants (antihistamines, benzodiazepines) as they impair central compensation 6