What are the causes and treatment options for vertigo in children?

Vertigo in Children: Causes and Treatment

Most Common Causes

Vestibular migraine and benign paroxysmal vertigo of childhood are the most common causes of vertigo in children, together accounting for approximately 40-60% of cases, followed by idiopathic causes, labyrinthitis/vestibular neuronitis, and otitis media. 1, 2, 3

Primary Diagnoses by Frequency

• Vestibular migraine accounts for 23.8% of pediatric vertigo cases and requires ≥5 episodes of vestibular symptoms with current or history of migraine, photophobia, phonophobia, or visual aura 1, 4
• Benign paroxysmal vertigo of childhood represents 13.7% of cases and is considered a migraine precursor syndrome 1, 5
• Idiopathic/unidentified causes account for 11.7% of cases 1
• Labyrinthitis/vestibular neuronitis represents 8.47% of cases and presents with acute prolonged vertigo without hearing loss (vestibular neuronitis) or with hearing loss (labyrinthitis) 1, 6
• Otitis media is a common peripheral cause, particularly in younger children 5
• Motion sickness is frequent and clinically relevant in children aged 4-10 years 3

Less Common but Important Causes

• Benign paroxysmal positional vertigo (BPPV) occurs in children but is less common than in adults, characterized by brief episodes (<1 minute) triggered by head position changes 6, 4
• Ménière's disease is rare in children, presenting with episodes lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness 6, 4
• Brainstem and cerebellar tumors are relatively more common in children than adults and must be actively excluded with MRI when central signs are present 3, 2
• Posttraumatic vertigo presents with vertigo, disequilibrium, tinnitus, and headache following head injury 7, 4

Critical Diagnostic Approach

Initial Clinical Evaluation

Focus on timing patterns and triggers rather than the child's description of dizziness to categorize into four syndromes: acute vestibular (days to weeks), triggered episodic (<1 minute with position changes), spontaneous episodic (minutes to hours without triggers), and chronic (weeks to months). 7

Essential History Elements

• Episode duration: <1 minute suggests BPPV; 5 minutes to 72 hours suggests vestibular migraine; 20 minutes to 12 hours suggests Ménière's disease; days to weeks suggests vestibular neuronitis or labyrinthitis 7, 4
• Triggers: Position changes (BPPV), no triggers (vestibular migraine, Ménière's), pressure changes (superior canal dehiscence) 7, 4
• Associated symptoms: Migraine features (vestibular migraine), hearing loss/tinnitus/aural fullness (Ménière's, labyrinthitis), ear pain/fever (otitis media) 6, 7
• Migraine history: Personal or family history of migraine strongly suggests vestibular migraine 7, 4

Physical Examination Priorities

• Dix-Hallpike maneuver: Peripheral causes produce torsional and upbeating nystagmus with latency (5-20 seconds), crescendo-decrescendo pattern, and resolution within 60 seconds; central causes produce immediate, persistent, purely vertical nystagmus without torsional component 7, 4
• Nystagmus characteristics: Horizontal with rotatory component, unidirectional, suppressed by visual fixation, and fatigable indicates peripheral; pure vertical, direction-changing, not suppressed by fixation indicates central 7
• Neurological examination: Dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia, or Horner's syndrome indicate central pathology requiring urgent neuroimaging 7, 4

Red Flags Requiring Immediate MRI

• Downbeating nystagmus on Dix-Hallpike without torsional component 7, 4
• Direction-changing nystagmus without head position changes 4
• Baseline nystagmus without provocative maneuvers 7, 4
• Severe postural instability with falling 7, 4
• Any additional neurological symptoms or signs 7, 4
• New-onset severe headache with vertigo 7
• Failure to respond to appropriate peripheral vertigo treatments 7, 4
• Subacute central vestibular signs warrant MRI due to relatively high frequency of brainstem and cerebellar tumors in children 3, 2

Diagnostic Testing Strategy

• Audiometry and tympanometry are the most helpful initial tests and should be performed in all children with vertigo 5
• Electronystagmography is useful in select cases when diagnosis remains unclear 5
• Brain MRI is necessary only if clinical examination reveals abnormal findings, particularly abnormal ocular motor testing or central vestibular signs 2, 3
• Routine neuroimaging is NOT recommended in diagnosed BPPV without red flags 7

Treatment Approach

Vestibular Migraine (Most Common)

• Nonpharmacologic prophylaxis should always be recommended first, including trigger identification and avoidance, sleep hygiene, hydration, and regular meals 2
• Behavioral support is useful when somatization is present 2
• Pharmacologic treatment evidence is largely based on adult populations, as high-quality controlled studies in children are sparse 2, 8

Benign Paroxysmal Vertigo of Childhood

• Reassurance and observation are often sufficient as this condition typically resolves spontaneously 5
• Recognition as a migraine precursor helps guide long-term management 1, 3

BPPV (When Present)

• Canalith repositioning procedures (Epley maneuver) are the primary treatment 6, 7
• Vestibular suppressant medications should NOT be used as they are inappropriate for BPPV 6
• Failure to respond to repositioning maneuvers should prompt reconsideration of the diagnosis 7, 4

Vestibular Neuronitis/Labyrinthitis

• Acute management focuses on symptom control during the acute phase 6
• Vestibular rehabilitation is recommended for persistent symptoms 7

Ménière's Disease (Rare in Children)

• Dietary sodium restriction 7
• Diuretics 7
• Vestibular rehabilitation 7

Motion Sickness

• Behavioral modifications and gradual exposure 3
• Pharmacologic options are available but should be age-appropriate 8

Critical Pitfalls to Avoid

• Missing central causes: 10% of cerebellar strokes present similar to peripheral vestibular disorders, and 75-80% of stroke-related acute vestibular syndrome patients have no focal neurologic deficits 4
• Overlooking vestibular migraine: This is under-recognized despite being the most common cause in children 7, 1
• Failing to distinguish fluctuating hearing loss (Ménière's disease) from stable/absent hearing loss (vestibular migraine) 7
• Inappropriate use of vestibular suppressants in BPPV 6
• Delaying MRI when central signs are present: Brainstem and cerebellar tumors are relatively more common in children than adults 3, 2
• Overlooking medication side effects as a cause of dizziness in children on multiple medications 7, 4

Prognosis

• Most children with vertigo have favorable outcomes: 79% are improved or asymptomatic with appropriate diagnosis and treatment 5
• Early correct diagnosis prevents unnecessary investigations, alleviates parental worries, and avoids chronic illness 3, 2
• More than 50% of dizzy children also have headache, highlighting the strong migraine-vertigo connection 2