Originally published at Pediatric EM Morsels on May  18, 2018. Reposted with permission.

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No 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, 2015; Erbek, 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
  • Arrhythmias (ex, Prolonged QTc)
  • Hypertension
• 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