Vertigo in Children: Diagnostic Evaluation & Management Tool

Clinical History Assessment

Systematic approach to history taking for a child presenting with vertigo or dizziness

Physical Examination Guide

Systematic approach to examining a child with vertigo or dizziness

Diagnostic Approach

Initial Assessment

For a child presenting with vertigo/dizziness, the initial assessment should include:

• Detailed history distinguishing true vertigo from non-vertiginous dizziness
• Complete neurological and otological examination
• Assessment of vestibular function
• Evaluation for potential red flags requiring urgent attention

Defining Vertigo vs. Other Types of Dizziness

Differentiating types of dizziness is essential for accurate diagnosis:

Type	Definition	Key Features
True Vertigo	Illusion of movement (spinning, rotating, tilting)	Vestibular origin, often with nystagmus, nausea
Disequilibrium	Feeling of imbalance without spinning sensation	Often cerebellar, proprioceptive, or musculoskeletal
Presyncope	Feeling of impending faint, lightheadedness	Cardiovascular origin, orthostatic changes
Non-specific Dizziness	Vague light-headedness, floating, swimming sensation	Often associated with anxiety, hyperventilation, metabolic disorders

Differential Diagnosis

System	Conditions	Red Flags
Peripheral Vestibular	- Benign Paroxysmal Vertigo of Childhood - Vestibular neuritis - Otitis media - Benign Paroxysmal Positional Vertigo - Vestibular migraine - Ménière's disease (rare in children)	- Hearing loss - Persistent vertigo >24 hours - Severe vomiting/dehydration - Otalgia with effusion
Central Nervous System	- Posterior fossa tumors - Chiari malformation - Basilar migraine - Vestibular epilepsy - Demyelinating disorders - Vertebrobasilar insufficiency	- Ataxia or gait disturbance - Headache with papilledema - Double vision or visual field defects - Progressive symptoms - Central nystagmus pattern - Altered consciousness
Cardiovascular	- Orthostatic hypotension - Cardiac arrhythmias - Vasovagal syncope - Long QT syndrome	- Syncope with exertion - Palpitations - Family history of sudden death - Chest pain - Significant orthostatic drop
Toxic/Metabolic	- Medication side effects - Hypoglycemia - Anemia - Dehydration - Post-concussion syndrome	- Recent medication changes - Exposure to ototoxic drugs - Recent head trauma - Altered mental status - Signs of dehydration
Psychogenic	- Anxiety disorders - Panic attacks - Hyperventilation syndrome - Functional dizziness	- Situational triggers - Associated panic symptoms - School avoidance - Inconsistent examination findings

Common Pediatric Vestibular Disorders

Key conditions causing vertigo in children:

Condition	Age	Clinical Features	Duration
Benign Paroxysmal Vertigo of Childhood (BPVC)	1-5 years	Sudden onset, pallor, nystagmus, no hearing loss, ability to return to activities	Minutes to hours
Vestibular Migraine	School-age	Recurrent vertigo, may have headache, family history of migraine, motion sensitivity	Hours to days
Vestibular Neuritis	Any age	Sudden severe vertigo, nausea/vomiting, unidirectional horizontal nystagmus, viral prodrome	Days to weeks
Post-concussive Vertigo	Any age	History of head trauma, headache, cognitive symptoms, balance problems	Weeks to months
Benign Paroxysmal Positional Vertigo (BPPV)	Rare in children	Position-dependent, brief, triggered by specific head movements	Seconds to minutes

Laboratory Studies

Consider these studies based on clinical suspicion:

Investigation	Clinical Utility	When to Consider
Complete Blood Count	Assess for anemia, infection	Fatigue, pallor, recurrent symptoms
Blood Glucose	Screen for hypoglycemia	Episodes related to fasting, diabetic patients
Electrolytes	Evaluate for electrolyte imbalances	Vomiting, dehydration, medication effects
Thyroid Function Tests	Screen for thyroid disorders	Associated symptoms of hypo/hyperthyroidism
ECG	Assess for cardiac arrhythmias	Palpitations, syncope, family history of cardiac disorders

Vestibular Testing

Specialized vestibular assessment:

Test	Purpose	When to Order
Video/Electronystagmography (VNG/ENG)	Evaluate nystagmus and vestibular function	Recurrent vertigo, abnormal bedside vestibular tests
Vestibular Evoked Myogenic Potentials (VEMP)	Assess saccular and utricular function	Suspected peripheral vestibular disorder
Rotatory Chair Testing	Evaluate vestibulo-ocular reflex	Suspected bilateral vestibular hypofunction
Audiometry	Assess hearing function	Vertigo with suspected hearing loss
Posturography	Evaluate balance and integration of sensory inputs	Balance problems, fall risk assessment

Imaging Studies

Reserved for specific clinical scenarios:

Investigation	Clinical Utility	When to Consider
MRI Brain with focus on IAC/posterior fossa	Evaluate for structural abnormalities	Focal neurological signs, persistent symptoms, abnormal hearing
CT Temporal Bone	Evaluate bony structures of middle/inner ear	History of trauma, congenital hearing loss, recurrent infections
MRA Head and Neck	Assess vascular structures	Suspected vertebrobasilar insufficiency, vascular anomalies

Diagnostic Algorithm

A stepwise approach to diagnosing vertigo in children:

1. Determine type of dizziness (true vertigo vs. non-vertiginous dizziness)
2. Assess for red flags requiring urgent evaluation (headache, neurological deficits, hearing loss)
3. Complete neurological and vestibular examination including nystagmus assessment
4. Consider peripheral vs. central causes based on examination findings
5. Perform bedside vestibular tests (Head Impulse Test, Dix-Hallpike)
6. Screen for orthostatic changes if presyncope is suspected
7. Consider laboratory studies based on clinical suspicion
8. Refer for specialized vestibular testing for recurrent or unclear cases
9. Obtain imaging only if red flags or abnormal examination findings
10. Consider common pediatric vestibular syndromes (BPVC, vestibular migraine)

Management Strategies

General Approach to Management

Key principles in managing pediatric vertigo:

• Accurate diagnosis: Distinguish between peripheral and central causes
• Symptomatic management: Control acute symptoms of vertigo and nausea
• Specific treatment: Address underlying cause when identified
• Vestibular rehabilitation: Consider for persistent symptoms or vestibular hypofunction
• Education and reassurance: Explain benign nature of most pediatric vertigo conditions
• Regular follow-up: Monitor for symptom evolution and treatment response

Acute Management of Vertigo

Intervention	Dosing/Implementation	Evidence Level and Considerations
Vestibular Suppressants	- Dimenhydrinate: 1-1.5 mg/kg/dose (max 50 mg) q6h PRN - Diphenhydramine: 1 mg/kg/dose (max 25-50 mg) q6h PRN - Meclizine: 12.5-25 mg q6h PRN (age >12 years)	- Moderate evidence for symptomatic relief - Short-term use only (3-5 days) - Can mask central causes - May cause drowsiness
Antiemetics	- Ondansetron: 0.15 mg/kg/dose (max 8 mg) q8h PRN - Promethazine: 0.25-1 mg/kg/dose (max 25 mg) q6h PRN (>2 years)	- High evidence for control of nausea/vomiting - Monitor for extrapyramidal symptoms - Ondansetron preferred in children
Hydration	- Oral rehydration if tolerated - IV fluids if significant vomiting	- Essential for patients with vomiting - May improve symptoms of orthostatic dizziness - Consider electrolyte monitoring
Environmental Modifications	- Quiet, darkened room - Minimal head movement - Supervised mobility	- Low evidence but clinically beneficial - Reduces sensory stimuli - Prevents falls and injury

Condition-Specific Management

Condition	Management Approach	Expected Outcome
Benign Paroxysmal Vertigo of Childhood (BPVC)	- Reassurance about benign nature - Safety measures during episodes - Consider prophylactic treatment if frequent (cyproheptadine, topiramate) - Trigger identification and avoidance	- Self-limiting condition - Resolution typically by age 5-8 years - May evolve into migraine in adolescence - Excellent prognosis
Vestibular Migraine	- Trigger identification and avoidance - Abortive therapy: ibuprofen, naproxen - Prophylactic therapy if frequent: cyproheptadine (younger children), topiramate, amitriptyline (adolescents) - Lifestyle modifications: regular sleep, meals, hydration	- Often chronic but manageable condition - Reduced frequency with prophylaxis - Better outcomes with combined approach - May require long-term management
Vestibular Neuritis	- Short course of vestibular suppressants (3-5 days) - Early mobilization and vestibular rehabilitation - Consider short course of corticosteroids in severe cases - Gradual return to activities	- Acute symptoms resolve in 1-3 weeks - Possible residual vestibular hypofunction - Vestibular rehabilitation improves outcomes - Low recurrence rate
BPPV	- Canalith repositioning procedures (modified Epley for children) - Home exercises if appropriate - Return precautions if symptoms recur	- Rapid resolution with correct maneuvers - Possible recurrence (20-30%) - Excellent long-term prognosis - Rarely chronic in children
Post-concussive Vertigo	- Gradual return to activities - Vestibular rehabilitation - Cognitive rest during acute phase - Symptomatic treatment - Consider neuropsychological evaluation	- Resolution within 1-3 months in most cases - Some may have prolonged symptoms - Better outcomes with early rehabilitation - Return to school/sports requires monitoring

Vestibular Rehabilitation

Evidence-based approach for persistent vertigo or balance disorders:

Type	Exercises	Indications and Evidence
Adaptation Exercises	- Head movement with visual fixation - VOR x1/x2 viewing paradigms - Progressive complexity of head movements	- High evidence for unilateral vestibular hypofunction - Promotes central compensation - Most effective when customized - Requires daily practice
Habituation Exercises	- Repeated exposure to provocative movements - Gradual increase in duration and intensity - Position change exercises	- Moderate evidence for motion sensitivity - Effective for BPPV - May reduce anxiety-related dizziness - Customized to specific triggers
Balance Training	- Static and dynamic balance activities - Sensory integration exercises - Dual-task activities - Proprioceptive training	- High evidence for improving falls risk - Effective for multiple vestibular disorders - Age-appropriate activities important - Progressive difficulty needed
Gait Training	- Walking with head movements - Obstacle courses - Varying surfaces and speeds - Turning activities	- Moderate evidence for functional improvement - Important for return to activities - Addresses common daily challenges - May prevent falls

Indications for Specialist Referral

Specialist	Indications for Referral	Timing
Pediatric Neurologist	- Focal neurological deficits - Abnormal eye movements - Suspected seizures or basilar migraine - Headache with concerning features - Persistent or progressive symptoms	- Urgent (same day): Focal deficits, altered consciousness - Soon (1-2 weeks): Recurrent unexplained vertigo, suspected central cause - Routine: Suspected migraine
Otolaryngologist	- Associated hearing loss - Chronic otitis media - Tympanic membrane perforation - Recurrent peripheral vertigo - Need for vestibular testing	- Soon (1-2 weeks): Sudden hearing loss, recurrent severe vertigo - Routine: Chronic conditions, need for specialized testing
Vestibular Therapist	- Persistent balance problems - Vestibular hypofunction - Post-concussion dizziness - Chronic vestibular disorders	- Soon (1-2 weeks): Acute vestibular neuritis - Routine: Chronic conditions, vestibular hypofunction
Cardiologist	- Syncope with exertion - Palpitations with dizziness - Abnormal ECG - Family history of sudden death - Orthostatic intolerance	- Urgent (same day): Concerning cardiac symptoms - Soon (1-2 weeks): Recurrent syncope - Routine: Mild orthostatic symptoms

Patient and Family Education

• Explanation of diagnosis: Age-appropriate explanations of vestibular system and symptoms
• Natural history: Expected course and prognosis of specific conditions
• Safety measures: Preventing falls, supervision during episodes
• Trigger management: Identification and avoidance of specific triggers
• School accommodations: Communication with school, temporary modifications if needed
• Home exercises: Demonstration and written instructions for vestibular exercises
• Return precautions: When to seek urgent care (new symptoms, worsening)

Follow-up Recommendations

• Initial follow-up: 1-4 weeks based on diagnosis and severity
• Monitoring parameters: Frequency of episodes, symptom severity, functional impact
• Medication adjustment: Evaluate efficacy and side effects of prescribed medications
• Vestibular rehabilitation progress: Assess compliance and response to exercises
• Developmental considerations: Monitor for impact on development and school performance
• Long-term follow-up: Consider periodic checks for conditions with increased risk of recurrence
• Transition planning: For chronic conditions requiring ongoing management into adulthood