Evaluation and Management of Pediatric Dizziness
Initial Clinical Approach
Categorize the dizziness by timing and triggers rather than relying on the child's subjective description of symptoms, as this classification directly guides diagnosis and management. 1, 2
The four key vestibular syndromes to distinguish are:
- Brief episodic vertigo (seconds): Suggests BPPV 1
- Spontaneous episodic vertigo (minutes to hours): Most commonly vestibular migraine 1
- Acute persistent vertigo (days to weeks): Consider vestibular neuritis or central pathology 1
- Chronic vestibular syndrome: Requires evaluation for structural or progressive disorders 2
Critical History Elements
Focus on these specific details rather than vague descriptions:
- Duration of episodes: Seconds point to BPPV, minutes to hours suggest vestibular migraine, days to weeks indicate vestibular neuritis or central causes 1
- Triggers: Head position changes strongly suggest BPPV; no clear trigger points toward vestibular migraine or Ménière's disease 1
- Associated symptoms:
Essential Physical Examination
Perform the Dix-Hallpike maneuver immediately in any child with positionally-triggered symptoms. 1, 2 This is mandatory, not optional.
Key examination components:
- Dix-Hallpike maneuver: Look for 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolving within 60 seconds 2, 3
- Neurologic examination: Specifically assess for focal deficits indicating central pathology 1
- Nystagmus assessment: Downbeating nystagmus or direction-changing nystagmus without head position change indicates central pathology 1
- Gait and balance testing: Inability to stand or walk independently requires urgent evaluation 1
Red Flags Requiring Urgent Evaluation
These findings mandate immediate imaging and specialist consultation:
- Focal neurological deficits 1
- Inability to stand or walk independently 1
- New severe headache 1
- Sudden unilateral hearing loss 1
- Downbeating nystagmus 1
- Loss of consciousness 1
- Unilateral or pulsatile tinnitus 2, 3
Critical pitfall: Posterior circulation stroke can present with NO focal neurologic deficits on standard examination—maintain high suspicion in acute persistent vertigo. 1, 2
Imaging Decisions
Do NOT order imaging for:
- Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 1
- Spontaneous episodic vertigo consistent with vestibular migraine 1
- Acute persistent vertigo with normal neurologic exam and clear peripheral features 1
Order MRI brain without contrast for:
- Any red flag symptoms listed above 1, 2
- Failure to respond to vestibular treatments 1
- Atypical presentation 1
- High vascular risk patients with acute persistent vertigo, even with normal exam 2
Never use CT head instead of MRI when stroke is suspected—CT has poor sensitivity for posterior circulation pathology. 1, 2
Common Diagnoses and Management
Vestibular Migraine (Most Common in Children)
Vestibular migraine accounts for approximately 40% of pediatric dizziness cases. 4, 5
Management approach:
- Behavioral therapy: Avoid triggers, maintain regular sleep schedule, adequate hydration 4
- Nonpharmacologic prophylaxis should always be recommended 5
- Consider prophylactic medications if episodes are frequent and disabling 5
BPPV
Perform canalith repositioning procedures (Epley maneuver) immediately—success rate is 90-98%. 2
- Counsel families about 10-18% recurrence risk at one year, up to 36% long-term 2
- Emphasize fall prevention, particularly important in this population 2
Vestibular Neuritis
- Typically presents with severe rotational vertigo lasting 12-36 hours with decreasing disequilibrium over 4-5 days 3
- No hearing loss, tinnitus, or aural fullness (distinguishes from labyrinthitis) 3
- Consider vestibular rehabilitation exercises 4
Somatoform Vertigo
- Incidence increases in adolescents 4
- Provide information about the disorder and behavioral advice—this alone often leads to improvement 4
- Psychotherapy useful in some cases; reserve drug therapy for severe cases 4
Diagnostic Yield Context
Understanding these numbers helps avoid overuse of imaging: