Evaluation and Management of Dizziness in Children

Initial Evaluation

The American Academy of Otolaryngology-Head and Neck Surgery suggests that the duration of episodes can help differentiate between benign paroxysmal positional vertigo (BPPV), vestibular migraine, and vestibular neuritis or central pathology, with seconds suggesting BPPV, minutes to hours suggesting vestibular migraine, and days to weeks suggesting vestibular neuritis or central pathology 2, 1
Triggers such as head position changes can point to BPPV, while no clear trigger may suggest vestibular migraine or Ménière's disease 2, 3
Associated symptoms like headache, photophobia, and phonophobia can strongly suggest vestibular migraine 1, 4
Hearing loss, tinnitus, or aural fullness may suggest Ménière's disease 2, 4
Fever and otalgia can suggest infectious labyrinthitis 2

The Dix-Hallpike maneuver is mandatory for any child with positionally-triggered symptoms to diagnose BPPV 3, 1
A neurologic examination should look specifically for focal deficits that indicate central pathology 5, 3
Nystagmus assessment can help identify central pathology, with downbeating nystagmus or direction-changing nystagmus without head position change being indicative of central pathology 3, 5
Gait and balance testing can help identify red flags, with inability to stand or walk independently requiring urgent evaluation 5

If brief episodic vertigo is present, the Dix-Hallpike maneuver should be performed immediately to diagnose BPPV 3, 1
If spontaneous episodic vertigo is present, vestibular migraine is the most likely cause, especially if the child has headache, photophobia, phonophobia, or family history of migraine 4, 6
If acute persistent vertigo is present, a full neurologic examination should be performed to look for focal deficits, and MRI brain without contrast should be obtained if the exam is abnormal or if the child has vascular risk factors 5, 1

Focal neurological deficits, inability to stand or walk independently, new severe headache, sudden unilateral hearing loss, downbeating nystagmus, or loss of consciousness require urgent evaluation and imaging 5
Posterior circulation stroke can present with no focal neurologic deficits on standard examination, so high suspicion should be maintained in acute persistent vertigo 5, 6

Imaging is not necessary for brief episodic vertigo with typical BPPV features, spontaneous episodic vertigo consistent with vestibular migraine, or acute persistent vertigo with normal neurologic exam and clear peripheral features 1
MRI brain without contrast should be ordered for red flag symptoms, unilateral or pulsatile tinnitus, failure to respond to vestibular treatments, or atypical presentation 1, 5
CT head has poor sensitivity for posterior circulation pathology and should not be used instead of MRI when stroke is suspected 5, 6