Dizziness, vertigo, and balance disorders in children

Dr. Jacob Brodsky, MD, FAAP, is the director of the Balance and Vestibular Program in the Boston Children’s Hospital Department of Otolaryngology and Communication Enhancement, as well as an assistant professor in the Department of Otology and Laryngology at Harvard Medical School.

Imagine that you wake up one morning and the world around you is spinning rapidly as if you were on a merry-go-round. You try to walk but the floor seems to be moving and you fall to the ground. You begin to feel nauseous. You lie down hoping the feeling will disappear, but it does not.

It can be a terrifying experience for a child to experience dizziness. Moreover, it can often be very difficult for them to articulate to their parents and doctors exactly what they are experiencing.

Most pediatric health care providers do not learn about the evaluation and management of dizziness in children during the course of their training. A child complaining of dizziness may appear normal and may not have any obvious abnormalities on physical exam, but the differential diagnosis of dizziness in children is expansive, ranging anywhere from simple dehydration to a vestibular or balance disorder to a brain tumor. For these reasons, the evaluation of a child with dizziness can often be an intimidating and time-consuming task.

A basic awareness of some of the most common causes of dizziness in children is the first step in the evaluation process. Equally important is understanding how they present. This can make it much easier to identify the root cause of dizziness. I find that you can narrow things down pretty quickly by following some of the guidelines below:

Terms that identify dizziness without using the word dizziness

When a child uses terms like “light-headed,” “heavy-headed,” “foggy,” “woozy,” or “cloudy,” this suggests more orthostatic, metabolic, or psychiatric causes, such as:

• dehydration
• anemia
• hypothyroidism
• anxiety
• a cardiac anomaly

Vestibular causes of dizziness typically present with true vertigo: a sensation of movement of one’s surroundings. Usually that movement is rotational, but it can also be a tilting or rocking or flipping sensation.

Duration of dizziness and provoking factors

The duration of vertigo and its provoking factors can be particularly helpful in determining its causes and appropriate treatment for the following:

1. Brief episodes of dizziness lasting seconds to minutes

Dizziness that comes on primarily with getting up quickly from sitting, or supine, and only lasts for a minute or two strongly supports an orthostatic, cardiac, or metabolic cause. This should prompt blood work, a cardiac assessment, and treatment with aggressive hydration and increased salt intake. If the dizziness is similarly brief but occurs primarily when supine, you should suspect benign paroxysmal positioning vertigo (BPPV), which can often be treated in the office with simple head maneuvers. BPPV results from displacement of otolith crystals in the inner ear into one of the semicircular canals.

There is very little in the medical literature on BPPV in children. Although it is often described as being rare in the pediatric population, we have found it to actually be remarkably common. Here at Boston Children’s Hospital, we have diagnosed and successfully treated BPPV in approximately 14 percent of pediatric patients seen at our program for dizziness, and approximately 20 percent of pediatric patients seen at our program for post-concussive dizziness. Unfortunately, most of these patients had seen many providers and had undergone extensive testing before coming to our program. Having their BPPV identified and treated resulted in an average delay of over five months from symptom onset to diagnosis.

To diagnose BPPV, simply lie your patient down quickly with their head tilted 45 degrees to the side until their head is hanging off the end of the exam table. This is called the Dix-Hallpike maneuver and is used to diagnose BPPV involving the posterior semicircular canals. Then lie your patient down with their neck flexed about 30 degrees and rotate their head to the right side. Then repeat the same maneuver to the left side. This is called the head roll maneuver and is used to diagnose BPPV of the horizontal semicircular canals.

Visible nystagmus or subjective vertigo in any of these positions confirms that BPPV is present. BPPV can be treated with head maneuvers performed in the office by a physical therapist or physician trained in the management of vestibular disorders. Supine dizziness can also occur with mass-occupying brain lesions including a Chiari malformation or arachnoid cyst. Thus, careful examination is required. Imaging should be considered if the exam is not typical of BPPV or if other neurologic symptoms or exam findings are present.

2. Long episodes of dizziness lasting hours to days

Episodes of vertigo that seem unprovoked and last for hours — particularly if accompanied by headache — are typical of vestibular migraine. Vestibular migraine is actually the most common cause of vertigo in pediatric patients and is also frequently under recognized. It is important to note that vestibular migraine does not need to include a headache and may consist of vertigo or motion sensitivity accompanied by other migrainous features, including photophobia or visual aura. Vestibular migraine is a clinical diagnosis and does not require vestibular testing unless the presentation is atypical. Vestibular migraine also responds to most conventional migraine medications.

3. Chronic dizziness lasting weeks to months

An episode of vertigo lasting several days is generally due to vestibular neuritis: a viral infection of the vestibular nerve that generally resolves spontaneously. Many patients with vestibular neuritis can often be left with residual, mild dizziness and potentially long-term balance deficits that can last for weeks, months, or even years. This can be avoided with high-dose steroids and a course of vestibular rehabilitation with an experienced physical therapist.

Persistent vertigo may also suggest labyrinthitis, an infection of the inner ear itself that presents similarly to vestibular neuritis but with hearing loss. Since that hearing loss can be permanent, complaints of vertigo accompanied by subjective hearing loss should prompt an urgent audiogram and ear examination.

Constant dizziness that lasts for weeks to months and that either does not vary in severity or is exacerbated by visual patterns, motion, grocery stores, or shopping malls is suggestive of persistent postural perceptual dizziness (PPPD). This is a somatoform disorder that typically occurs in the setting of a recovered peripheral vestibular disorder (such as vestibular neuritis) compounded by baseline anxiety. This disorder has been formally described by a number of different names, including chronic subjective dizziness (CSD), postural phobic vertigo, and visual vertigo. PPPD has been shown in randomized controlled trials in adults to respond well to habituation-based vestibular rehabilitation with a physical therapist, cognitive behavioral therapy, and selective serotonin reuptake inhibitor (SSRI) therapy.

Learn more about Boston Children’s Balance and Vestibular Program.