What is the initial management for dizziness in a pediatric patient?

Management of Dizziness in a 15-Year-Old Pediatric Patient

The initial management of dizziness in a 15-year-old should focus on distinguishing benign paroxysmal positional vertigo (BPPV) from other causes through targeted history and physical examination, followed by particle repositioning maneuvers if BPPV is confirmed, while avoiding routine vestibular suppressant medications. 1

Initial Diagnostic Approach

Critical History Elements

• Timing and triggers: Determine if dizziness is episodic (seconds to minutes), acute persistent (hours to days), or chronic 1, 2
• Quality of symptoms: Distinguish true vertigo (illusion of motion) from presyncope, disequilibrium, or lightheadedness 3, 4
• Positional triggers: Ask specifically about symptoms triggered by head movements or position changes, which strongly suggest BPPV 1, 2
• Associated symptoms: Screen for hearing loss, tinnitus, neurological symptoms, or cardiovascular symptoms 3, 5

Essential Physical Examination

• Dix-Hallpike maneuver: Perform this for any patient with triggered episodic dizziness to diagnose posterior canal BPPV 1, 2
• Orthostatic vital signs: Measure blood pressure supine and standing to exclude orthostatic hypotension 2, 5
• Neurological examination: Assess for focal deficits, cerebellar signs, or cranial nerve abnormalities 3, 4
• Nystagmus assessment: Observe for spontaneous nystagmus at rest and with positional testing 1, 3

Treatment Based on Diagnosis

If BPPV is Confirmed

Particle repositioning maneuvers are the definitive treatment, with success rates of 78.6-93.3% for the Epley maneuver, compared to only 30.8% with medication alone. 1

• Posterior canal BPPV: Perform the Epley maneuver 1
• Lateral canal BPPV: Use the Gufoni maneuver or barbecue roll maneuver 1
• Avoid vestibular suppressants: Meclizine and similar medications should not be routinely prescribed for BPPV, as they do not address the underlying cause and may delay recovery 1, 6

If Non-BPPV Peripheral Vertigo

• Short-term vestibular suppressants only: Use meclizine (typical dosing for adolescents similar to adults) or benzodiazepines only for severe acute symptoms, not as definitive treatment 6
• Transition to vestibular rehabilitation: Begin Cawthorne-Cooksey or Brandt-Daroff exercises as soon as acute symptoms improve to promote central compensation 1, 6
• Avoid prolonged medication use: Long-term vestibular suppressants interfere with central compensation and natural adaptation 6, 7

Important Medication Cautions in Adolescents

Vestibular suppressant medications cause significant side effects including drowsiness, cognitive deficits, interference with driving, and are an independent risk factor for falls. 6

• Meclizine should be used PRN rather than scheduled to avoid interfering with vestibular compensation 6
• Benzodiazepines may help with psychological anxiety secondary to vertigo but should be limited to short-term use 6
• Prochlorperazine can be used for severe nausea/vomiting but is not primary treatment for vertigo itself 6

What NOT to Do

• Do not order routine imaging: Radiographic imaging or vestibular testing is not indicated for straightforward BPPV unless diagnosis is uncertain or neurological symptoms are present 1
• Do not prescribe meclizine as primary BPPV treatment: This delays definitive treatment with repositioning maneuvers 1, 6
• Do not use aspirin-containing products: Avoid aspirin in patients ≤18 years with nausea/vomiting due to Reye's syndrome risk 7

Follow-Up Requirements

Reassess all patients within 1 month after initial treatment to confirm symptom resolution or identify treatment failures. 1, 6

• Complete symptom resolution is expected for successful BPPV treatment 1
• Persistent symptoms warrant reevaluation for incorrect initial diagnosis, involvement of different semicircular canals, or underlying peripheral vestibular or CNS disorders 1
• BPPV recurrence rates range from 10-18% at 1 year, so patient education about recurrence is essential 8

Special Considerations for Adolescents

• Adolescents may experience psychological anxiety related to vertigo symptoms, which can be addressed with short-term benzodiazepines if needed 6
• Education about safety implications, particularly fall risk, is important even in younger patients 8, 1
• Home-based vestibular rehabilitation is equally effective as clinician-supervised therapy 1