How should I evaluate and manage a 15‑year‑old adolescent presenting with dizziness?

Evaluation and Management of a 15-Year-Old with Dizziness

Begin by determining the timing and triggers of the dizziness—specifically whether episodes last seconds, minutes, hours, or days, and whether they are provoked by head position changes, standing, or occur spontaneously—because this temporal pattern is far more diagnostically useful than the adolescent's subjective description of the sensation. 1, 2

Initial History: Critical Elements

Focus on these specific details:

• Duration of each episode: Seconds suggest benign paroxysmal positional vertigo (BPPV, 42% of vertigo cases); minutes to hours suggest vestibular migraine (14% of cases) or Ménière's disease; days to weeks suggest vestibular neuritis (41% of peripheral vertigo) 1, 2

• Triggers: Head position changes point to BPPV; standing from supine suggests orthostatic hypotension (cardiovascular, not vestibular); spontaneous episodes suggest vestibular migraine or Ménière's 1, 2

• Associated symptoms:

  • Hearing loss, tinnitus, or aural fullness → Ménière's disease 1, 2
  • Headache, photophobia, phonophobia, visual aura → vestibular migraine (extremely common and under-recognized in adolescents) 1, 2
  • Neurologic symptoms (dysarthria, diplopia, limb weakness, dysphagia) → central cause requiring urgent imaging 1

• Trauma history: Post-traumatic vertigo can present with persistent vertigo, disequilibrium, tinnitus, and headache 2

• Medication review: Antihypertensives, anticonvulsants (Mysoline, carbamazepine, phenytoin), and cardiovascular drugs can cause dizziness 1, 2

Physical Examination: Mandatory Components

Perform these specific maneuvers:

1. Dix-Hallpike Maneuver (Bilateral)

• Execute even if the patient does not describe classic "spinning," because 50% of BPPV patients report only lightheadedness or vague imbalance 3
• Positive findings (BPPV): 5–20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolve within 60 seconds, fatigability with repeat testing 1, 2
• Red-flag findings (central pathology): Immediate onset, persistent nystagmus, purely vertical (up- or downbeating) without torsional component → urgent MRI required 1

2. Supine Roll Test

• If Dix-Hallpike is negative, perform this to detect lateral-canal BPPV (10–15% of BPPV cases) 1

3. Orthostatic Vital Signs

• Measure blood pressure and heart rate supine, then at 1 and 3 minutes standing 2
• In adolescents, consider postural orthostatic tachycardia syndrome (POTS): heart rate increase ≥30 bpm (or ≥40 bpm in ages 12–19) with orthostatic intolerance, most common in young women 2

4. Neurologic Examination

• Cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements), gait assessment, and assessment for nystagmus at baseline 3
• Any focal deficit (dysarthria, limb weakness, diplopia, Horner's syndrome) mandates immediate MRI 1, 3

5. Hearing Assessment

• Weber and Rinne tests: Asymmetric hearing loss requires formal audiometry and MRI to exclude vestibular schwannoma or central pathology 1, 2

Red Flags Requiring Urgent MRI Brain (Without Contrast, With Diffusion-Weighted Imaging)

Order immediate imaging if any of the following are present:

• Severe postural instability with falling 1
• New-onset severe headache with vertigo 1, 3
• Any focal neurologic deficit (dysarthria, limb weakness, sensory loss, diplopia, dysphagia, Horner's syndrome) 1, 3
• Downbeating or purely vertical nystagmus without torsional component 1
• Direction-changing nystagmus without head position changes 1
• Baseline nystagmus present without provocative maneuvers 1
• Sudden unilateral hearing loss 2, 3
• Inability to stand or walk 2, 3
• Failure to respond to appropriate peripheral vertigo treatments 1

Critical pitfall: 75–80% of posterior-circulation strokes present without focal neurologic deficits, so a normal neurologic exam does not exclude stroke 2, 3

When Imaging Is NOT Indicated

Do not order CT or MRI for:

• Typical BPPV with positive Dix-Hallpike and no red flags (diagnostic yield <1%) 1, 2, 3
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 2, 3

Note: CT head has <1% diagnostic yield for isolated dizziness and misses most posterior-circulation infarcts (sensitivity 10–20%); if imaging is needed, MRI is mandatory 2, 3

Treatment Based on Diagnosis

BPPV (Most Likely in Adolescents with Brief Positional Episodes)

Perform the Epley (canalith repositioning) maneuver immediately upon positive Dix-Hallpike 1, 2, 3

• Success rate: 80% after 1–3 treatments; 90–98% with additional maneuvers 1, 2
• Do not prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines)—they prevent central compensation and delay recovery 1, 2
• Reassess within 1 month; counsel about 10–18% recurrence at 1 year 3

Vestibular Migraine (Extremely Common and Under-Recognized in Adolescents)

• Diagnostic criteria: Episodic vestibular symptoms + migraine by International Headache Society criteria + at least two migraine symptoms (headache, photophobia, phonophobia, visual aura) during at least two vertiginous episodes 1, 2
• Key distinguishing feature from Ménière's: Stable or absent hearing loss (not fluctuating) 1, 2
• Treatment: Migraine prophylaxis and lifestyle modifications (identify triggers such as motion intolerance, light sensitivity) 1, 2

Orthostatic Hypotension / POTS

• Increase fluid and salt intake, compression stockings, gradual position changes 2
• If refractory, consider alpha agonists or mineralocorticoids 4

Vestibular Neuritis

• Acute persistent vertigo lasting days to weeks without hearing loss 1, 2
• Vestibular suppressants only for acute phase (first 2–3 days), then early vestibular rehabilitation to promote central compensation 2, 5

Follow-Up and Counseling

• Reassess within 1 month to document resolution or persistence 1, 3
• Fall-risk counseling: Dizziness increases fall risk 12-fold; assess home safety, especially if symptoms persist 2, 3
• Recurrence education: BPPV recurs in 10–18% at 1 year, up to 36% long-term; instruct patient to return promptly for repeat Epley if symptoms recur 3

Common Pitfalls to Avoid

• Relying on the patient's description of "spinning" vs. "lightheadedness"—focus on timing and triggers instead 2, 3, 4
• Failing to perform Dix-Hallpike because the patient does not describe classic vertigo—50% of BPPV patients report atypical symptoms 3
• Assuming a normal neurologic exam excludes stroke—most posterior-circulation strokes lack focal deficits 2, 3
• Ordering CT instead of MRI when central pathology is suspected—CT misses most posterior-circulation infarcts 2, 3
• Overlooking vestibular migraine in adolescents—it accounts for 14% of all vertigo but is markedly under-diagnosed in young patients 1, 2
• Prescribing vestibular suppressants for BPPV—they do not correct the mechanical problem and delay recovery 1, 2