Pearls from Your Peers
Jennifer Alyono, MD, discusses pediatric dizziness with Kristen Steenerson, MD
What are the most common causes of dizziness in children?
The most common causes in children reflect the causes in adults—benign paroxysmal positional vertigo (BPPV), vestibular migraine, and orthostasis. Following that are functional neurologic disorders—3PD, or persistent postural perceptual dizziness. Anywhere from 15% to 20% of dizziness cases are BPPV in children, especially if there is a history of trauma or concussion.
What is your general approach to a child with dizziness?
Look at timing and triggers. Is this episodic versus chronic? If it’s episodic, what’s the general time frame? Is it mostly seconds? Minutes? Hours? Days?
Ask about triggers: Is there a position change versus a postural change? Here, “position” means a head position change, versus postural, which is standing versus sitting or lying. Those differentiate hemodynamic versus BPPV versus migraine. Migraine can cause position change sensitivity, but you can also ask about more classic migraine triggers such as stress, dehydration, or a hormone fluctuation for catamenial events.
Do kids with vestibular migraine have headaches?
No. In fact, the vast majority don’t. That’s why it was originally called benign paroxysmal vertigo of childhood before a terminology change to vestibular migraine of childhood in newly published guidelines in the Journal of Vestibular Research.
What might clue you in to vestibular migraine as the etiology?
There are interesting migraine equivalents that grow with us starting with infantile colic and benign paroxysmal torticollis of infancy. Then later in childhood, there is vestibular migraine of childhood or recurrent vertigo of childhood where you have potentially no typical migraine features. Motion sickness, growing pains, unexplained abdominal pain, and Raynaud’s disease have been associated with migraine later in life. There’s also the adult spectrum of equivalents like “sinus headaches” without sinus disease, ice cream headaches or brain freeze, or exquisite sensitivity to barometric pressure or altitude changes.
What do you recommend for workup?
Start with your history and physical with a good neuro-developmental exam. Are patients meeting motor and communication milestones? If there are no concerning findings, including a hearing screen, then you don’t have to necessarily do additional testing. But if there’s any concern for not meeting milestones, if patients have hearing loss, those should be red flags that you should get formal audiometry and vestibular testing.
When is imaging indicated?
Imaging follows a similar type of rule. If a neurological exam is normal, no hearing loss, you don’t have to do imaging. But if so, then usually magnetic resonance imaging for brain and vestibulocochlear nerve and computed tomography to look for bony malformations.
What are treatments for pediatric dizziness?
For BPPV, in-office repositioning or formal vestibular physical therapy is an option. Migraine follows similar patterns to adults—lifestyle changes ensuring adequate sleep, exercise, hydration, and stress management. These measures can be really helpful for most kids. If not, you can use medications ranging from topiramate to tricyclic antidepressants to migraine nutraceuticals.
What do you think the biggest difference between pediatric and adult dizziness is?
Some studies have reflected that in kids with hearing loss, even just from otitis media, 70% will have a vestibular loss in the long term as well. The mechanism is not clear and highly debated. But the point of bringing it up is that it probably is important to do some type of balance screen on someone you’re seeing for hearing loss alone. This could be as simple as having them stand on one foot and identifying if they match with their age group the number of seconds they stand.
What are red flags we shouldn’t miss?
These include progressive loss of hearing or balance function, regressing in milestones, missing out on school, missing out on social activities, new headaches, vision changes, loss of consciousness, and syncope.
The other thing I should mention is the episodic ataxias because a lot of patients have first onset in childhood. You have a channelopathy that causes cerebellar dysfunction for minutes to hours to days. You can have isolated vertigo, but you can also have downbeat nystagmus, dysarthria, or truncal or appendicular ataxia—more classic cerebellar phenomena. Why they’re important is that some of them are exquisitely responsive to acetazolamide so you can really change someone’s life.