Vertigo in Children

VertigoNo one likes to feel dizzy and, certainly, no one likes feeling as if the the room is spinning (unless you are competing in a game of Dizzy-Bat). When an adult has vertigo, I get queasy too. The severe causes can look very similar to the benign ones in adults, but what about with kids? What issues do I need to contemplate in children presenting with vertigo? Let us take a minute to digest a Morsel of goodness on Vertigo in Children:

 

Vertigo: Basics

  • Dizziness is a common complaint. [Davitt, 2017]
  • Vertigo is an illusion of motion.
    • May be described as a “spinning” or “whirling.”
    • “Dizzy” is often the initial complaint, but it is not descriptive enough to be overtly helpful.
      • Unfortunately, children may lack the vocabulary to better describe their feelings.
      • Children may also lack the experience to understand their sensations.
  • Children vs Adults
    • Children will have a more difficult time describing symptoms (although, not all adults are proficient in verbal communication of their symptoms either).
    • Children may be more difficult to appreciate their nystagmus.
    • Children will be more likely have vertigo related to migraines.
    • Children will be less likely to have Meniere’s disease.
    • Children will be less likely to have vascular etiology.

 

Vertigo: Causes

Vertigo in children “does not commonly represent a life-threatening or serious illness.” [Davitt, 2017]

Common Causes in children who have normal tympanic membranes. [Davitt, 2017; Raucci, 2016; Erbek, 2006]

  • Migraine-Associated Vertigo [Davitt, 2017; Raucci, 2016; Erbek, 2006]
    • Most common condition associated with vertigo (other than Otitis Media)
    • Vertigo may present before, during, or without headache.
    • Neuro exam should be normal.
    • More common in children than adults.
  • Benign Paroxysmal Vertigo of Childhood (BPVC)
    • Recurrent, brief attacks of vertigo.
    • Attacks occur without warning and resolve spontaneously.
    • Typically seen in children < 5 years of age. [Raucci, 2016]
    • Can be associated with pallor, perspiration, fearfulness, nausea, vomiting, phonophotophobia, and syncope. [Batu, 2015Erbek, 2006]
    • Vertigo does not have relation to head position (different from BPPV).
    • Vertigo is not associated with loss of consciousness (different from seizure)
    • Has a favorable prognosis and resolves after 6-12 months.
    • May be a part of a migraine complex, like cyclic vomiting and abdominal migraine.
  • Seizure
    • Loss of consciousness associated with vertigo warrants consideration of seizure as cause.
    • Staring episodes are also seen. [Batu, 2015]
  • Labyrinthitis / vestibular neuronitis
    • Follows an upper respiratory tract infection frequently
  • Syncope / Orthostatic hypotension / POTS
  • Psychogenic
    • More prevalent in older children (> 10 years of age)
    • It is always reasonable to screen for underlying psychiatric disorders.
    • Vertigo associated with anxiety, depression, and behavior disorders are seen. [Erbek, 2006]
  • Benign Paroxysmal Peripheral Vertigo (BPPV) [Brodsky, 2017]
    • Consists of short-duration vertigo attacks related to head position.
    • Less common in children than adults, but does occur.
    • More likely to be seen in teenagers.
  • Ocular Causes
    • Amblyopia
    • Astigmatism
    • Oculomotor abnormalities
  • Many encounters will ultimately be described as “Idiopathic

 

Uncommon, But Concerning Causes

Life-threatening disorders presenting with vertigo do occur, but “appear at an extremely low rate.”  [Davitt, 2017]

  •  Trauma
    • Skull fractures
  • Cardiac Causes
  • CNS Causes
    • Tumors
    • Demyelinating disease
    • Fortunately, patients “in whom severe neurological pathologies were diagnosed presented with associated signs or symptoms” and vertigo was not an isolated clinical feature. [Raucci, 2016]

 

Vertigo: Evaluation in the ED

Since the overwhelming majority of cases of vertigo in children will be due to a benign etiology, it is our job to mindfully screen for the rare, life-threatening conditions while being reasonable guardians of our resources.

  • A thorough Neurologic and HEENT exam is imperative. [Raucci, 2016; Erbek, 2006]
    • Otitis is a very common cause of vertigo (~50%)… don’t overlook the simple.
    • Episodes of unsteadiness may be the child exhibiting symptoms of vertigo. [Batu, 2015]
  • Check the Blood Pressure. [Raucci, 2016; Batu, 2015]
    • Seems simple… but it is also easy to overlook.
    • While rare, hypertensive crisis may present with vertigo… so check the BP.
  • Check the ECG. [Batu, 2015]
    • While the likelihood of a cardiac cause is low, don’t underestimate the power of a simple piece of paper with squiggly lines on it.
    • Look for arrhythmia provoking conditions (ex, Prolonged QTc, Brugada)
  • Imaging?
    • It is unlikely that a head CT will be of much value unless your neurologic exam is concerning for hemorrhage or overt mass.
    • MRI will be more useful at imaging the posterior fossa and demyelinating disease… but, with the majority of cases being due to benign and self-limited conditions, emergent imaging is rarely beneficial. [Raucci, 2016; Batu, 2015]
  • Outpatient Referral
    • Recommend ophthalmological evaluation as outpatient. [Batu, 2015]
      • Refractory errors may be the cause of vertigo…
      • They can also exacerbate vertigo even if they are not the cause.
    • Referral to multidisciplinary team may be beneficial. [Erbek, 2006]
      • Outpatient EEG and MRI may be warranted for evaluation of possible seizures.
      • Other benign conditions, like migraines and BPVC, have medical therapies available.

 

Moral of the Morsel

  • The Odds are in Your Favor! Most vertigo in children is related to benign causes (ex, migraines).
  • Don’t overlook the obvious! Check the TMs. Look for trauma.
  • Do simple screening! Check the ECG and BP!
  • Look for signs of underlying Neurological or Cardiac causes.

 

References

Brodsky JR1,2, Lipson S1, Wilber J1,3, Zhou G1,2. Benign Paroxysmal Positional Vertigo (BPPV) in Children and Adolescents: Clinical Features and Response to Therapy in 110 Pediatric Patients. Otol Neurotol. 2018 Mar;39(3):344-350. PMID: 29287036. [PubMed] [Read by QxMD]

Davitt M1, Delvecchio MT, Aronoff SC. The Differential Diagnosis of Vertigo in Children: A Systematic Review of 2726 Cases. Pediatr Emerg Care. 2017 Oct 31. PMID: 29095392. [PubMed] [Read by QxMD]

Raucci U1, Vanacore N2, Paolino MC3, Silenzi R4, Mariani R1, Urbano A3, Reale A1, Villa MP3, Parisi P5. Vertigo/dizziness in pediatric emergency department: Five years’ experience. Cephalalgia. 2016 May;36(6):593-8. PMID: 26378081. [PubMed] [Read by QxMD]

Brodsky JR1, Cusick BA2, Zhou G3. Evaluation and management of vestibular migraine in children: Experience from a pediatric vestibular clinic. Eur J Paediatr Neurol. 2016 Jan;20(1):85-92. PMID: 26521123. [PubMed] [Read by QxMD]

Batu ED1, Anlar B2, Topçu M3, Turanlı G4, Aysun S5. Vertigo in childhood: a retrospective series of 100 children. Eur J Paediatr Neurol. 2015 Mar;19(2):226-32. PMID: 25548116. [PubMed] [Read by QxMD]

Lee CH1, Lee SB, Kim YJ, Kong WK, Kim HM. Utility of psychological screening for the diagnosis of pediatric episodic vertigo. Otol Neurotol. 2014 Dec;35(10):e324-30. PMID: 25144643. [PubMed] [Read by QxMD]

Erbek SH1, Erbek SS, Yilmaz I, Topal O, Ozgirgin N, Ozluoglu LN, Alehan F. Vertigo in childhood: a clinical experience. Int J Pediatr Otorhinolaryngol. 2006 Sep;70(9):1547-54. PMID: 16730074. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. Health_Kenya says:

    Having a child in pain can be heartbreaking to watch, even more so when they exhibit symptoms we may be unfamiliar with. Complaints of dizziness and nausea for short periods of time can be confusing, and we don’t think of children as having issues with vertigo.

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