What are the causes and treatment options for dizziness in a pediatric patient?

Dizziness in Children: Causes and Management

Most Common Causes

Vestibular migraine and benign paroxysmal vertigo (migraine precursors) are the most common diagnoses in pediatric dizziness clinics, accounting for 30-60% of cases. 1

Primary Etiologies by Frequency

• Vestibular migraine accounts for up to 14% of all vertigo cases with a lifetime prevalence of 3.2%, and is extremely common in young patients 2, 3
• Benign paroxysmal positional vertigo (BPPV) is the single most common cause of vertigo overall (42% in general practice), though less common in children than adults 2, 3
• Migraine equivalent disorders represent a major category in pediatric populations 4
• Otitis media with effusion is one of the most common causes of balance disturbances specifically in young children, causing deterioration in balance and increased falls during episodes 5
• Ophthalmologic disorders are a frequent etiology in children 4
• Benign paroxysmal idiopathic pediatric vertigo is a distinct pediatric entity 4
• Somatoform/orthostatic dizziness accounts for a significant proportion of cases 1
• Post-traumatic dizziness including temporal bone fractures 4

Critical Diagnostic Approach

Initial Categorization by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery recommends categorizing vertigo into four distinct syndromes based on timing rather than descriptive terms 2:

• Triggered episodic (<1 minute): BPPV, postural hypotension 2
• Spontaneous episodic (minutes to hours): Vestibular migraine, Ménière's disease 2
• Acute vestibular syndrome (days to weeks): Vestibular neuritis, labyrinthitis, posterior circulation stroke 2
• Chronic (weeks to months): Anxiety disorders, medication effects, posterior fossa masses 2

Essential History Elements

• Episode duration: BPPV lasts <1 minute; vestibular migraine 5 minutes to 72 hours; Ménière's disease 20 minutes to 12 hours 2, 3
• Triggers: Position changes suggest BPPV; spontaneous onset suggests vestibular neuritis or central causes 2
• Associated otologic symptoms: Fluctuating hearing loss, tinnitus, and aural fullness indicate Ménière's disease 2, 3
• Migraine features: Headache, photophobia, phonophobia, visual aura during at least 50% of dizzy episodes suggests vestibular migraine 2, 6
• Trauma history: Post-traumatic vertigo and temporal bone fractures are important pediatric causes 4
• Middle ear disease: Otitis media with effusion commonly causes balance problems in young children 5

Physical Examination Priorities

Dix-Hallpike Maneuver (Essential for BPPV Diagnosis)

Peripheral (BPPV) findings 2:

• Torsional and upbeating nystagmus with 5-20 second latency
• Crescendo-decrescendo pattern
• Fatigues with repeat testing
• Resolves within 60 seconds

Central pathology findings requiring urgent neuroimaging 2, 3:

• Immediate onset without latency
• Persistent nystagmus that doesn't fatigue
• Purely vertical without torsional component (downbeating is particularly concerning)
• Baseline nystagmus present without provocative maneuvers

Nystagmus Characteristics

Peripheral vertigo 2:

• Horizontal with rotatory component
• Unidirectional
• Suppressed by visual fixation
• Fatigable with repeated testing

Central vertigo 2, 6:

• Pure vertical without torsional component
• Direction-changing without head position changes
• Not suppressed by visual fixation
• Gaze-evoked nystagmus

Neurological Red Flags Demanding Immediate MRI

The following require urgent neuroimaging 2, 3, 6:

• Severe postural instability with falling
• New-onset severe headache with vertigo
• Downbeating nystagmus on Dix-Hallpike without torsional component
• Any additional neurological symptoms (dysarthria, dysmetria, dysphagia, limb weakness, hemiparesis, truncal/gait ataxia, diplopia, Horner's syndrome)
• Failure to respond to appropriate peripheral vertigo treatments
• Purely vertical nystagmus without torsional component

Specific Pediatric Considerations

Vestibular System Development

• The vestibular and balance systems are largely developed after 1 year of age, making clinical and laboratory testing reliable in older infants and children 1

When Imaging is NOT Needed

• Typical BPPV with positive Dix-Hallpike and no red flags does not require neuroimaging 2, 3
• The diagnostic yield of CT in isolated dizziness is <1%; MRI is only 4% 2
• Most cases of childhood dizziness settle with time, and investigations should be carefully selected 7

When Imaging IS Required

• Brain MRI to exclude brainstem tumor or posterior fossa lesions is necessary only if clinical examination (particularly ocular motor testing) is abnormal 1
• Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders 2
• Approximately 25% of patients with acute vestibular syndrome have cerebrovascular disease 2, 3

Treatment Approach by Diagnosis

BPPV

• Perform canalith repositioning procedure (Epley maneuver) immediately if Dix-Hallpike is positive 2
• Do NOT prescribe vestibular suppressants for BPPV as they prevent central compensation 2
• Vestibular rehabilitation exercises are appropriate 2

Vestibular Migraine

• Nonpharmacologic prophylaxis should always be recommended 1
• Dietary modifications and lifestyle interventions 2
• Requires migraine symptoms during at least two vertiginous episodes to distinguish from BPPV 2

Ménière's Disease

• Dietary sodium restriction 2
• Diuretics 2
• Vestibular rehabilitation 2

Otitis Media with Effusion

• Address the middle ear disease as balance deterioration and increased falls occur during episodes 5
• Consider both hearing and balance effects in management 5

Symptomatic Treatment (When Appropriate)

• Dimenhydrinate or labyrinthine sedatives may be beneficial for troublesome vertigo 7
• Surgical intervention only required for operable lesions 7

Critical Pitfalls to Avoid

• Misdiagnosis of stroke: 10% of cerebellar strokes mimic peripheral vestibular disorders 2, 3
• Overlooking vestibular migraine: Despite being extremely common (>5% of school-aged children have vertigo/dizziness of at least moderate severity), it remains under-recognized 2, 1
• Failing to distinguish fluctuating versus stable hearing loss: Fluctuating hearing loss indicates Ménière's disease; stable/absent hearing loss suggests vestibular migraine 2
• Requesting unnecessary imaging: CT/MRI scanning is often requested but unnecessary in most cases without red flags 4
• Overlooking medication side effects: Anticonvulsants (phenytoin, carbamazepine, Mysoline), antihypertensives, and cardiovascular drugs can cause vestibular symptoms 2, 6
• Missing multiple concurrent vestibular disorders: BPPV can coexist with Ménière's disease or vestibular neuritis 2
• Ignoring the impact on quality of life: More than 50% of dizzy children also have headache, and dizziness causes considerable restrictions in school and leisure activities 1

Prognosis and Counseling

• Most conditions causing vertigo and dizziness in childhood are treatable 1
• Making a correct diagnosis early with appropriate counseling and treatment may avoid chronic illness 1
• Behavioral support is useful in somatization 1
• Evidence for drug therapy effectiveness is largely based on adult populations, as high-quality controlled studies in pediatric cohorts are sparse 1