What should I do if a child is experiencing dizziness and headaches?

Immediate Assessment and Risk Stratification

A child with recent onset of dizziness and headaches requires a thorough neurological examination to identify red flags, followed by nonopioid analgesics (ibuprofen or acetaminophen) for symptomatic relief, with the critical decision point being whether any abnormal findings necessitate emergent neuroimaging or whether this represents a benign primary headache or vestibular migraine.

Initial Clinical Evaluation

The first priority is performing a complete neurological examination including:

• Vital signs with blood pressure measurement to detect hypertension suggesting increased intracranial pressure 1
• Fundoscopic examination to identify papilledema, which indicates increased intracranial pressure 1
• Cranial nerve assessment, motor and sensory testing, cerebellar function, and gait evaluation to detect focal deficits 1
• Mental status assessment to identify altered consciousness 1

The combination of dizziness and headache is common, with more than 50% of dizzy children also experiencing headache 2. This symptom complex most frequently represents vestibular migraine or benign paroxysmal vertigo as a migraine precursor, accounting for 30-60% of diagnoses in pediatric dizziness clinics 2.

Critical Red Flags Requiring Immediate Action

If ANY of the following are present, emergent neuroimaging with CT without contrast is mandatory:

• Abnormal neurological examination findings including papilledema, focal deficits, or altered mental status 1
• Severe or "worst ever" headache 1
• Progressive or worsening symptoms 1
• Headache that awakens the child from sleep 3
• Age less than 6 years 3
• Occipital location of headache (rare in children and warrants caution) 1
• Associated vomiting, especially if intractable 3

Common pitfall: Do not skip fundoscopic examination, as it is essential for detecting increased intracranial pressure and has a nearly 2% risk of intracranial injury even with seemingly mild presentations 1, 4.

Management Algorithm Based on Examination Findings

If Neurological Examination is Normal:

Primary headaches are most likely, and neuroimaging has very low yield (<1% clinically significant findings) 1.

Immediate symptomatic treatment:

• Administer ibuprofen (10 mg/kg every 6-8 hours, maximum 400 mg per dose) or acetaminophen (15 mg/kg every 4-6 hours, maximum 650 mg per dose) as first-line therapy 4, 5
• Never prescribe opioids for headache, as they worsen outcomes 4, 5
• Limit acute medication use to no more than 2-3 days per week to prevent analgesic overuse and rebound headache 4

Supportive measures:

• Encourage adequate hydration, rest in a quiet dark environment, and cool compresses 4
• Implement proper sleep hygiene to facilitate recovery 4, 5

Vestibular assessment for dizziness:

• If subjective or objective evidence of vestibulo-oculomotor dysfunction persists, refer to a program of vestibular rehabilitation 6, 5
• Vestibular and oculomotor dysfunction may contribute to longer symptom duration 6

If Any Abnormal Neurological Findings:

Emergent neuroimaging is mandatory 1:

• CT without contrast for acute evaluation if concerned about hemorrhage 1
• MRI without contrast is preferred for non-emergent evaluation of suspected tumor or structural lesions 1

Follow-Up Strategy

Provide clear return precautions:

• Return immediately if headache worsens or becomes severe 4
• Return for new symptoms including vomiting, confusion, vision changes, or weakness 4

Schedule follow-up at 2-4 weeks to reassess symptom trajectory 4:

• If symptoms persist beyond 2 months, recognize this as chronic headache requiring multidisciplinary evaluation 4, 5
• Refer for multidisciplinary evaluation including pediatric neurology, reassessment for analgesic overuse, and evaluation for comorbid sleep disturbance or mood disorders 4, 6

Specific Considerations for Trauma History

If there is any history of head trauma (even minor):

• Children with GCS scores 13-15 carry a 1.9% risk of intracranial complications 4
• Severe or worsening headache after trauma requires CT imaging 6, 4
• Post-traumatic headache requires the same nonopioid analgesic approach with careful monitoring for progression 6, 5

Most Likely Diagnoses

Given normal examination:

• Vestibular migraine or benign paroxysmal vertigo (30-60% of cases with dizziness and headache) 2
• Primary migraine (21.8-66.3% of pediatric ED headaches) 3
• Orthostatic dizziness contributing to symptoms 2
• Somatoform dizziness 2

Nonpharmacologic prophylaxis should always be recommended in vestibular migraine 2.