Vertigo in childhood: a retrospective series of 100 children

Vertiginous epilepsy in the pediatric population

Vertiginous epilepsy (VE) is a rare and underrecognized epilepsy subtype in the pediatric population. Vertiginous symptoms are the sole or predominant feature, arise from the vestibular cortex, and seizures are usually brief. The incidence is estimated to be between six and 15 percent of pediatric patients presenting with dizziness. Diagnosis is often delayed for many years following the onset of symptoms, as there are no widely accepted diagnostic criteria. Diagnostic work-up should include a detailed history, physical exam, EEG, and brain imaging with MRI. Vestibular testing is helpful if peripheral vestibulopathy is suspected. Vertiginous epilepsy can have many possible causes, but a large majority are idiopathic or suspected to be genetic. Most patients with vertiginous epilepsy achieve seizure freedom with anti-seizure medications.

Characteristics and diagnostic approach of vestibular migraine in children and adolescents: A systematic review

OBJECTIVE

Vestibular migraine (VM) is the most common cause of episodic vertigo afflicts 1% of the general population. The complexity of VM is owing to the migrainous, and vestibular components and much knowledge have been gained in recent years on VM in the adult population. Akin to that, numerous studies focusing on VM in children and adolescent has emerged. We reviewed the literature to understand the characteristics and diagnostic approach of VM in children and adolescents.

METHODS

A literature search was conducted over a period of one month (April 2022).

RESULTS

16 articles were selected based on our objective and selection criteria. A total of patients was included, with a median age of 10.9 years. 11 studies diagnosed VM based on diagnostic criteria. Caloric test and electro/videonystagmography are the most favoured investigation used (50%). Imaging was performed in 56.2% of included studies.

CONCLUSION

Deciphering the ideal diagnostic approach for VM is prudent to ensure children and adolescents suffering from VM are treated earlier. VM can be diagnosed using the established diagnostic criteria, which requires thorough and meticulous history taking. The available oto-neurological examination aims to exclude other disorders as its significance in diagnosing VM is still debatable.

Benign paroxysmal vertigo of childhood

Benign paroxysmal vertigo of childhood (or recurrent vertigo of childhood) is the most common cause of vertigo in young children. It is considered a pediatric migraine variant or precursor disorder, and children with the condition have an increased likelihood of developing migraine later in life than the general population. Episodes are typically associated with room-spinning vertigo in conjunction with other migrainous symptoms (e.g. pallor, nausea, etc.), but it is rarely associated with headaches. Episodes typically only last for a few minutes and occur with a frequency of days to weeks without interictal symptoms or exam/test abnormalities. Treatment is rarely necessary, but migraine therapy may be beneficial in cases where episodes are particularly severe, frequent, and/or prolonged. An appreciation of the typical presentation and characteristics of this common condition is essential to any provider responsible for the care of children with migraine disorders and/or dizziness. This chapter will review the current literature on this condition, including its proposed pathophysiology, clinical presentation, and management. This chapter also includes a brief introduction to pediatric vestibular disorders, including relevant anatomy, physiology, embryology/development, history-taking, physical examination, testing, and a review of other common causes of pediatric dizziness/vertigo.

Etiological classification and management of dizziness in children: A systematic review and meta-analysis

Background

Dizziness in children, which could not be diagnosed at an early stage in the past, is becoming increasingly clear to a large extent. However, the recognition of the diagnosis and management remains discrepant and controversial due to their complicated and varied etiology. Central and peripheral vestibular disorders, psychogenic and systemic diseases, and genetic pathogeny constitute childhood etiological entities. Further understanding of the etiology and the prevalence of vertigo disorders is of crucial importance and benefit in the diagnosis and management of pediatric patients.

Methods

This systematic review and meta-analysis were conducted by systematically searching Embase, PubMed, the Cochrane Library, CNIK, the Chinese Wan-Fang database, CBM, the Chinese VIP database, and the Web of Science for literature on childhood vertigo disorders published up to May 2022. The literature was evaluated under strict screening and diagnostic criteria. Their quality was assessed using the Agency for Healthcare and Research Quality (AHRQ) standards. The test for homogeneity was conducted to determine the fixed effects model or random-effect model employed.

Results

Twenty-three retrospective cross-sectional studies involving 7,647 children with vertigo disorders were finally included, with an AHRQ score >4 (high or moderate quality). Our results demonstrated that peripheral vertigo (52.20%, 95% CI: 42.9-61.4%) was more common in children than central vertigo (28.7%, 95% CI: 20.8-37.4%), psychogenic vertigo (7.0%, 95% CI: 4.8-10.0%), and other systemic vertigo (4.7%, 95% CI: 2.6-8.2%). The five most common etiological diagnoses associated with peripheral vertigo included benign paroxysmal vertigo of childhood (BPVC) (19.50%, 95% CI: 13.5-28.3%), sinusitis-related diseases (10.7%, 95% CI: -11.2-32.6%), vestibular or semicircular canal dysfunction (9.20%, 95% CI: 5.7-15.0%), benign paroxysmal positional vertigo (BPPV)(7.20%, 95% CI: 3.9-11.5%), and orthostatic dysregulation (6.8%, 95% CI: 3.4-13.0%). Vestibular migraine (20.3%, 95% CI: 15.4-25.2%) was the most seen etiological diagnosis associated with central vertigo in children. In addition, we found the sex-based difference influenced the outcome of psychogenic vertigo and vestibular migraine, while there was no significant difference in other categories of the etiology. For the management of vertigo, symptomatical management is the first choice for most types of vertigo disorder in pediatrics.

Conclusion

Complex etiology and non-specific clinical manifestations of vertigo in pediatrics are challenging for their diagnoses. Reliable diagnosis and effective management depend on the close cooperation of multiple disciplines, combined with comprehensive consideration of the alternative characteristics of vertigo in children with growth and development.

A Preliminary Study on the Characteristics and Standard Diagnosis and Treatment of Vestibular Dysfunction in Children

OBJECTIVE

To understand the pathogenesis of vestibular dysfunction in children and to provide a reference for the diagnosis and treatment of vestibular dysfunction in children.

METHODS

A retrospective analysis was conducted on 80 children who visited our hospital from June 2011 to July 2020, aged between 4 and 17 years, with a duration of 1 day to 3 years. They were admitted to the hospital for treatment upon vestibular function-related examinations confirmed that there was peripheral vestibular function impairment.

RESULTS

Children aged 6-12 years old who are diagnosed are significantly more than other two age groups (4-6) and (12-17) (X2 = 101.738, P < .001). There was a significant statistical difference (X2 = 91.195, P < .001) in comparison of abnormal rates of vestibular function-related examinations. The Mann test had the highest abnormal rate and the lowest Cervical Vestibular Evoked Myogenic Potential (cVEMP) abnormality rate. Comparison of abnormal consistency rates for quantitative and qualitative examination of vestibular function, the abnormal rates (double temperature test and Mann test) were significantly better than other abnormal consistency rates, and there were statistical differences (X2 = 7.485, P = .024 < .05). Among the children with vestibular dysfunction, the etiology was most common in 58 cases (72.50%) of benign paroxysmal vertigo, 4 cases of vestibular migraine (5.00%), 8 cases (10.00%) of vestibular neuronitis, of which 22 cases (27.50%) were combined with other diseases, and the most common was 15 cases (18.75%) of sinusitis.

CONCLUSION

A limited number of studies were conducted on vestibular dysfunction in children. The current retrospective analysis suggests that age, gender, and side of ear pain have no significant effects, while children aged 6-12 are more likely to suffer from vestibular dysfunction. On children's vestibular dysfunction, more etiology is unclear, and special attention should be paid to differential diagnosis when giving treatment and the child's medical history should be examined in detail and appropriate vestibular function tests should be selected in order to provide timely, effective, and accurate treatment for the child.

Episodic ataxias in children and adolescents: Clinical findings and suggested diagnostic criteria

Background

The main clinical presentation of episodic ataxias (EAs) consists of vertigo and dizziness attacks lasting for minutes to hours with widely varying accompanying symptoms. The differentiation of EA and episodic vertigo/dizziness syndromes in childhood and adolescence such as vestibular migraine (VM) and recurrent vertigo of childhood (RVC) can be challenging. Furthermore, only few prospective studies of children/adolescents with EA are available.

Objective

This study aims to characterize clinical and instrument-based findings in EA patients under 18 years of age, to delineate the clinical and therapeutic course in EA, and to present potentially new genetic mutations. Furthermore, the study aims to differentiate distinct characteristics between EA, VM, and RVC patients.

Methods

We prospectively collected clinical and instrument-based data of patients younger than 18 years, who presented at the German Center for Vertigo and Balance Disorders (DSGZ) at the LMU University Hospital in Munich with EA, VM, or RVC between January 2016 and December 2021. All patients underwent a comprehensive evaluation of neurological, ocular-motor, vestibular and cochlear function, including video-oculography with caloric testing, video head impulse test, vestibular evoked myogenic potentials, posturography, and gait analysis.

Results

Ten patients with EA, 15 with VM, and 15 with RVC were included. In EA the main symptoms were vertigo/dizziness attacks lasting between 5 min and 12 h. Common accompanying symptoms included walking difficulties, paleness, and speech difficulties. Six EA patients had a previously unknown gene mutation. In the interictal interval all EA patients showed distinct ocular-motor deficits. Significant differences between EA, VM, and RVC were found for accompanying symptoms such as speech disturbances and paleness, and for the trigger factor “physical activity”. Furthermore, in the interictal interval significant group differences were observed for different pathological nystagmus types, a saccadic smooth pursuit, and disturbed fixation suppression.

Conclusion

By combining clinical and ocular-motor characteristics we propose diagnostic criteria that can help to diagnose EA among children/adolescents and identify patients with EA even without distinct genetic findings. Nevertheless, broad genetic testing (e.g., next generation sequencing) in patients fulfilling the diagnostic criteria should be conducted to identify even rare or unknown genetic mutations for EA.

Clinical characteristics of vestibular evoked myogenic potentials in children with recurrent vertigo of childhood

OBJECTIVE

To explore the possible pathogenesis of recurrent vertigo of childhood (RVC) and the clinical diagnosis value of vestibular-evoked myogenic potentials (VEMPs).

METHODS

The clinical data of 19 children (5.95 ± 0.38 years) diagnosed with RVC and 17 normal children (5.35 ± 0.31 years) enrolled in the control (NC) group from April 2017 to February 2021 was collected and analyzed. All subjects were tested for both cervical VEMP (cVEMP) and ocular VEMP (oVEMP). The elicit rate, thresholds, N1 latency, P1 latency, interval, amplitude, and amplitude asymmetry ratio (AAR) of VEMPs were compared and analyzed between the two groups.

RESULTS

(1) The elicit rates of cVEMP and oVEMP have no significant difference between the two groups (P > 0.05). (2) The thresholds of cVEMP and oVEMP in the RVC group were higher than that in the NC group (P < 0.05). (3) The N1 latency of cVEMP in the RVC group was longer than that in the NC group (P < 0.05). The P1 latency of cVEMP and latencies of oVEMP have no significant difference between the two groups (P > 0.05). (4) The interval of cVEMP in the RVC group was longer than that in the NC group (P < 0.05), while the interval of oVEMP has no significant difference between the two groups (P > 0.05). (5) The amplitude of cVEMP in the RVC group was higher than that in the NC group (P < 0.05), while the amplitude of oVEMP was similar in the two groups (P > 0.05). (6) The AAR values of oVEMP and cVEMP were similar in the two groups (P > 0.05).

CONCLUSIONS

The elicit rates of VEMPs in children with RVC did not differ from that of normal children, but the thresholds were all increased, suggesting reduced sensitivity of the otolith organ and vestibular nerve conduction pathways. The P1 latency of cVEMP was normal in children with RVC, but N1 latency and interval of cVEMP were increased, we finally reached a conclusion that there might be potential impairment in the inferior vestibular nerve and the subsequent nerve conduction pathway in RVC.

Indicators of pediatric peripheral vestibular disorder: A retrospective study in a tertiary referral center

OBJECTIVES

This study aims to present characteristics of pediatric patients with peripheral vertigo and dizziness and their clinical workup results in the tertiary otorhinolaryngology center. We wanted to investigate whether the detailed history could replace the extensive vestibular testing and whether the clinical presentation could guide the first contact physician to appropriately directed specialist referral.

METHODS

Retrospective case review of consecutive pediatric vertigo and dizziness patients referred to the tertiary otorhinolaryngology center from 2015 to 2020. The data about the signs and symptoms of vertigo and dizziness and the results of audiological and vestibular tests were collected.

RESULTS

Of 257 children aged 10.9±4.3 years (R: 1-17 years), 32 (12.5%) had peripheral, and 49 (19%) had central vertigo and dizziness. Acute vestibulopathy was diagnosed in 22/257 (8.5%) children, sudden sensorineural hearing loss and benign paroxysmal positional vertigo in 5/257 (2%) children each. 60% of children with peripheral vertigo and dizziness had emesis, and 55.6% had nausea. 8% of children had spontaneous horizontal-rotatory nystagmus that followed Alexander's law. Goodman and Kruskal's л for determining whether the type of nystagmus could predict the type of vertigo and dizziness (central or peripheral) was 0.481 (p = 0.001). 12/26 (60%) of children with peripheral vertigo and dizziness had emesis compared to 14 (30.04%) children without emesis, a difference in proportions of 0.296 (p = 0.024, chi-square test of homogeneity). Binomial logistic regression to ascertain the effects of duration, nausea and emesis on the likelihood of the presence of peripheral vertigo was statistically significant (χ2(3) = 10.626, p = 0.014).

CONCLUSION

Unlike adults, peripheral vestibular causes of vertigo and dizziness in children may be rare but have the same typical signs and symptoms. The detailed history and careful clinical examination are crucial in differentiating between peripheral and central causes. This guides the first contact physician for further referral to appropriate specialists included in a multidisciplinary workup. Namely, nausea, emesis, horizontal nystagmus and a longer duration of symptoms in a child with vertigo and dizziness indicate a peripheral etiology. Therefore, a referral to an otorhinolaryngologist is reasonable.

Prevalence of Pediatric and Adolescent Balance Disorders: Analysis of a Mono-Institutional Series of 472 Patients

(1) Background: To assess the prevalence and frequency distribution of balance disorders in children and adolescents to delineate the planning of a targeted clinical and instrumental diagnostic work-up; (2) Methods: Retrospective analysis of the clinical documentation of patients under 18 years suffering from balance disorders from 2010 to 2019. Detailed collection of clinical history, accurate clinical examination, including both nystagmus and vestibulospinal signs examinations, and specific instrumental testing were the basis of the diagnostic process. (3) Results: A total of 472 participants were included in the study. Vestibular loss (26.1%) was the most frequent cause of vertigo in children, followed by vestibular migraine (21.2%) and benign paroxysmal positional vertigo (10.2%). In 1.1% of patients, the cause of vertigo remained undefined; (4) Conclusions: The diagnostic process applied was effective in understanding the cause of balance disorders in most cases and prevents more complex and expensive investigations reserved for only a few selected cases.

Unraveling the Etiology of Pediatric Vertigo and Dizziness: A Tertiary Pediatric Center Experience

Background and Objectives: Numerous authors have reported that the commonest type of vertigo in children is migraine-associated vertigo (vestibular migraine and benign paroxysmal vertigo of childhood—BPV). We aimed to provide the possible etiological background of vertigo and dizziness in Slovenian children. Materials and Methods: A retrospective case series of pediatric vertigo and dizziness children referred to the tertiary pediatric otorhinolaryngology center from 2015 to 2020. Children received a complete audiological and vestibular workup and were referred to pediatric specialists depending on the clinical presentation. Results: Of 257 children (42% male, 58% female) aged 1–17 years (M = 10.9, SD = 4.3 years) in 19.1% vertigo and dizziness were classified as central, in 12.4% as a peripheral vestibular, in 10.9% as a hemodynamic, in 5.8% as a psychological and none as visual by pediatric neurologists, otorhinolaryngologists, cardiologists, psychologists or ophthalmologists, respectively. 40.8% (20) children with central vertigo had BPV (7.8% of all children) and 8.2% (4) migrainous vertigo. In 43.6% (112 children), the etiology remained unclassified. Conclusions: After a thorough multidisciplinary workup, the etiology of vertigo and dizziness was unraveled in the majority of children referred to our tertiary otorhinolaryngology center. The most common cause was central; however, in a considerable number, the etiology remained unclassified. The latter could be attributed to the self-limiting nature of vertigo spells. Hence, a child presenting with dizziness and vertigo requires a multidisciplinary approach, in which referral to a neurologist is, in most cases, essential.

How often do neurological disorders lead to dizziness in childhood?

Objective

The aim of the study was to determine the features and differential diagnosis of childhood dizziness and find out the prevalence of neurological diseases in children who were referred to the pediatric neurology outpatient clinic. A secondary aim was to evaluate the outcome of dizziness after 12 months.

Material and Methods

The records of children with a complaint of dizziness that were referred to the pediatric neurology outpatient clinic were retrospectively reviewed, and detailed medical and family history, clinical characteristics, laboratory investigations including vitamin B12 levels, and neuroimaging tests were analyzed. Patients were grouped as neurological disorders and non-neurological disorders. Neurological disorders included vestibular migraine, benign paroxysmal vertigo, and epilepsy, and non-neurological disorders contained the remaining disorders.

Results

The study consisted of 60 children (36 females, 24 males) with a mean age of 11.7±4.1 years. The most common diagnoses were vestibular migraine (21.7%) and orthostatic hypotension (20%). We found that the incidence of neurological diseases was 40% (vestibular migraine, 21.7%; epilepsy, 10%; benign paroxysmal vertigo, 8.3%). When we compared the neurological disorders with non-neurological disorders, there was a significant difference in terms of age at onset and duration of attacks (p=0.001 for both), whereas no significant difference was detected in terms of gender, frequency of attacks, and vitamin B12 levels. We detected ongoing symptoms in 10% of the patients who were diagnosed with vestibular migraine and psychogenic dizziness.

Conclusion

Both non-neurological and neurological diseases are common in etiology of children with dizziness.

Clinical and demographic characteristics of children and adolescents with acute vertigo symptoms: A cross-sectional study

Background/aim

Vertigo is one of the rarely diagnosed disorders during childhood due to insufficient description of the children regarding their experiences to the physicians. The clinical features of children and adolescents admitted by acute vertigo symptoms were investigated to elaborate the subject retrospectively.

Materials and methods

Between January 2017–July 2019, records of cases admitted with acute vertigo complaints to pediatric neurology were retrospectively examined.

Results

Of 761 patients, mean age was 13.8 years, 64% (n = 487) were women, 22.6% (n = 172) of which were children (1–11 years). A total of 37.3% of the cases (n = 284) had unknown etiology of acute vertigo symptoms, 39.6% (n = 301) had acute vertigo, and 23.1% (n = 176) were considered with no organicity problems but a group of the families stopped cooperating to the full extent in the study. Among all the patients, 25.6% (195/761) had paroxymal vertigo, 6.8% (52/761) had migraine-associated vertigo, 4.5% (34/761) had psychogenic vertigo, and 2.6% (20/761) had epileptic vertigo. Epileptic vertigo was significantly higher in younger children (mean age = 10.6, F(3) = 8874, P < .001), and the ratio of its occurence was also higher among children (60%, χ2 (3) = 20.347, P < .001).

Conclusion

Vertigo complaints are 1.7 times more common among the girls. Epileptic vertigo is significantly higher among the children. Among younger children, it seems important to consider epilepsy when vertigo emerged.

Vestibular and balance disorders in Mexican children and adolescents: Review of 8-year clinical records

INTRODUCTION

Vertigo is a seldom studied symptom in the paediatric population, where the prevalence is less than 1%. Vestibular disorders in children are not comparable to those of adults and are often underdiagnosed. Identifying the main causes of these disorders would provide reliable and accurate data of the diseases in certain age groups, improving the diagnostic process.

MATERIAL AND METHODS

Observational, cross-sectional, and retrospective study. Consecutive records of patients, aged 3 to 17years, attended due to vestibular, balance and associated symptoms (vertigo, dizziness, hearing loss, balance disorders and headache), attended by the otoneurology service of a tertiary hospital, between September 2010 and September 2018, were included. Descriptive and inferential statistics were used for the analysis. All p-values reported from these analyses were two-tailed with a significance level <.05.

RESULTS

212 cases were registered from 6,444 consultations (3.3%). The proportion between males and females was similar. The mean age of the group was 14.5 (±3.9) years, the median age of onset of symptoms was 11 (IQR 8-14) years and that of the first consultation was 13 (IQR 10-15) years. As a cardinal symptom, 51.9% attended due to vertigo, 25.5% due to dizziness, 9.9% due to gait instability, 7.5% due to hearing loss and 5.2% due to headache. Of the episodes of vertigo, 61.8% were of peripheral origin, 69 32.5% central and 12 5.7% outside the vestibular system. Benign paroxysmal vertigo of childhood, dysfunction and vestibular migraine accounted for more than 65% of cases. No differences were found between the diagnoses regarding the sex and age of the participants (P>.05).

CONCLUSION

Vestibular and balance disorders are rare in the study population and most of the causes are benign and potentially self-limited disorders.

The Differential Diagnosis of Vertigo in Children: A Systematic Review of 2726 Cases

OBJECTIVES

Vertigo is a relatively common complaint in children with 5.3% of pediatric patients complaining of this symptom. Although the causes of vertigo have been well established in adults, the diagnoses in children have not been well described. The aims of this systematic review are to discover the current information regarding etiologies of vertigo in children and to determine the most common diagnoses that present with vertigo in pediatric patients.

METHODS

PubMed, Scopus, and Embase were searched using the PRISMA guidelines. The inclusion and exclusion criteria were established a priori. All results were analyzed using a Bayesian methodology for point estimation and credible interval calculation.

RESULTS

From the database searches, 1419 titles were reviewed. Twenty-two studies met inclusion criteria. From these studies, a total of 2726 children aged 2 months to 19 years were reported. The top 4 diagnoses associated with childhood vertigo include vestibular migraine (23.8%; credible interval, 22.3%-25.5%), benign paroxysmal vertigo of childhood (13.7%; credible interval, 12.4%-15%), idiopathic or no identified association (11.7%; credible interval, 10.5%-12.9%), and labyrinthitis/vestibular neuronitis (8.47%, credible interval, 7.46%-9.55%) accounting for approximately 57% of cases. Less common diagnoses included Meniere disease and central nervous system tumors.

CONCLUSIONS

Although the most common causes of pediatric vertigo include vestibular migraine and benign paroxysmal vertigo of childhood, the etiologies are myriad. Rates and credible intervals are provided to permit a probabilistic diagnostic approach to these children.

Pediatric Migraine: An Update

This article outlines key features of diagnosis and treatment of migraine in children and adolescents. It emphasizes techniques that can be used by clinicians to optimize history taking in this population, as well as recognition of episodic conditions that may be associated with migraine and present in childhood. Acute treatment strategies include use of over-the-counter analgesics and triptan medications that have been approved by the US Food and Drug Administration for use in children and adolescents. Preventive treatment approach includes lifestyle modifications, behavioral strategies, and consideration of preventive medications with the lowest side effect profiles.

Vestibular migraine: An update on current understanding and future directions

BACKGROUND

Vestibular migraine is among the most common causes of recurrent vertigo in the general population. Despite its prevalence and high impact on healthcare cost and utilization, it has remained an under-recognized condition with largely unknown pathophysiology. In the present article, we aim to provide an overview of the current understanding of vestibular migraine.

METHODS

We undertook a narrative literature review on the epidemiology, presentations, clinical and laboratory findings, pathophysiology, and treatments of vestibular migraine.

RESULTS

Currently, the diagnosis of vestibular migraine relies solely on clinical symptoms since clinical tests of vestibular function are typically normal, or difficult to interpret based on inconsistent results reported in earlier studies. The challenges related to diagnosis of vestibular migraine lie in its relatively broad spectrum of manifestations, the absence of typical migraine headaches with vestibular symptoms, and its very recent definition as a distinct entity. Here, we highlight these challenges, discuss common vestibular symptoms and clinical presentations in vestibular migraine, and review the current aspects of its clinical diagnosis and evaluation. The concepts related to the pathophysiology and treatment of vestibular migraine are also discussed.

CONCLUSION

Vestibular migraine is still underdiagnosed clinically. Future studies are needed to address the pathophysiological mechanisms and investigate effective treatment regimens.

(Doctor…My child keeps falling over) unexpected MRI findings in children with history of frequent falls and dizziness: a case series

Frequent falls and dizziness are common complaints in children. These symptoms can be caused by wide range of underlying pathologies including peripheral vestibular deficits, cardiac disease, central lesions, motor skills delay and psychogenic disorders. We report three paediatric cases who presented with complaints of repeated falls and imbalance. MRI scan revealed underlying brain lesions (frontal lobe arteriovenous malformation, exophytic brain stem glioma and cerebellomedullary angle arachnoid cyst with cerebellar tonsillar ectopia). By reporting these cases, we would like to emphasise the importance of a thorough assessment of children with similar symptoms by detailed clinical history, physical examination and maintaining low threshold for investigations, including radiological imaging. Taking in consideration, the wide range of differential diagnosis, the challenge of obtaining detailed history and difficulty of performing reliable physical examination in this age group. Management of underlying disorders can be medical, surgical or just observational.

Episodic syndromes of childhood associated with migraine

PURPOSE OF REVIEW

This review covers recent advances in our understanding of episodic syndromes that may be associated with migraine in children and adolescents, as well as what is known about the treatment of these disorders.

RECENT FINDINGS

The episodic syndromes include benign paroxysmal torticollis, benign paroxysmal vertigo, abdominal migraine, and cyclic vomiting syndrome. Infant colic, or excessive crying in an otherwise healthy and well fed infant, may also fit into this category and is included in the appendix section of the most recent edition of the International Classification of Headache Disorders.

SUMMARY

Episodic syndromes are considered to be early life expressions of migraine in the developing brain. Additional research is needed to determine, which acute and preventive treatments are the most effective in managing these disorders.

Benign paroxysmal positional vertigo in children

OBJECTIVE

To describe the clinical features of benign paroxysmal positional vertigo (BPPV) in children.

DESIGN

A retrospective study.

SETTING

Six children diagnosed with BPPV between March 2014 and March 2015 were retrospectively evaluated. BPPV was diagnosed using the Dix-Hallpike and supine roll tests and treated with either the modified Epley particle repositioning procedure or Lempert or Gufoni manoeuvre. Follow-up was performed at 1-week intervals until vertigo and nystagmus disappeared during positional testing.

PARTICIPANTS

A total of six children were followed up for a period of 10-22 months.

MAIN OUTCOME MEASURES

Clinical features such as history, nystagmus and symptoms of vertigo, dizziness and nausea.

RESULTS

Six children were diagnosed with BPPV using positional testing and treated with the modified Epley or Lempert/Gufoni particle repositioning procedures. Four children were diagnosed with posterior canal BPPV, while the remaining two were diagnosed with horizontal canal BPPV. One girl reported a history of head trauma, one girl had a family history of vertigo, and one boy reported hearing loss in the same ear as that affected by BPPV. Overall, 83.33% of children (5/6) were completely relieved of vertigo following one treatment session. The remaining child was asymptomatic after two sessions. No child reported relapse of vertigo during the follow-up period.

CONCLUSIONS

BPPV can be diagnosed accurately by taking a detailed medical history and by use of positional testing. BPPV in children can be successfully identified and treated.

Do pre-school episodic syndromes predict migraine in primary school children? A retrospective cohort study on health care data

OBJECTIVE

To assess the relative risk, predictive value and population attributable risk fraction of pre-school episodic syndromes for later migraine in primary school age children.

METHODS

This retrospective cohort study used health insurance data on 55,035 children born in 2006 with no diagnosis of migraine up to the age of 5 years. The relative risk, probability and population attributable risk fraction of migraine prompting a physician visit at the age of 6-10 years in children with episodic syndromes included in the International Classification of Headache Disorders (benign paroxysmal torticollis, benign paroxysmal vertigo, cyclic vomiting syndrome, recurrent abdominal symptoms and abdominal migraine) and those not included in the International Classification of Headache Disorders (pavor nocturnus, somnabulism and bruxism) diagnosed up to the age of 5 years were determined.

RESULTS

The period prevalence of individual episodic syndromes ranged between 0.01% and 1.40%. For episodic syndromes included in the International Classification of Headache Disorders (recurrent abdominal symptoms and abdominal migraine) and for the episodic syndromes not included in the International Classification of Headache Disorders (somnambulism), the risk for later migraine was increased by factors of 2.08, 21.87 and 3.93, respectively. The proportion of risk for migraine in primary school children explained by any episodic syndromes included in the International Classification of Headache Disorders was 2.18% and for any episodic syndromes not included in the International Classification of Headache Disorders it was 0.59%.

CONCLUSION

Several pre-school episodic syndromes are risk factors for migraine in primary school age children. The fraction of migraine in primary school age children explained by prior episodic syndromes, however, is below 3%. A probability to develop primary school age migraine above 50% was only observed for abdominal migraine.

Vertigo in children; a narrative review of the various causes and their management

Vertigo is a not an uncommon symptom in children, but often the treating doctors are unsure of the diagnosis and the management of these cases. This narrative review of the literature discusses the brief etiopathology, the clinical manifestations and the management algorithm of most of the conditions causing vertigo in children. The relevant information has been condensed into a table for the perusal of the readers, which would assist in the appropriate management of these children.

Vestibular Migraine: Clinical Challenges and Opportunities for Multidisciplinarity

Migraine and vertigo are two very prevalent conditions in general population. The coexistence of both in the same subject is a significant clinical challenge, since it is not always possible to understand whether they are causally related or associated by chance, requiring different diagnostic and therapeutic approaches. In this review we analyze and summarize the actual knowledge about vestibular migraine (VM), focusing on the new concepts proposed by the International Classification of Headache Disorders 3-beta and by the Bárány Society and also addressing the former concepts, which are still present in clinical practice. We conclude that clinical studies using a multidisciplinary approach are crucial in this field, since different specialists observe the same pathology with different eyes. Clinical presentation of VM is variable in what concerns vestibular symptoms temporal relation with migraine headache, as well as in their accompanying manifestations. Biomarkers, either genomics or functional, and molecular imaging techniques will be helpful to clarify many aspects of the complexity of this entity, helping to define to what extent can VM be considered a separate and independent clinical entity.

Vestibular migraine: the most frequent entity of episodic vertigo

Vestibular migraine (VM) is the most common cause of episodic vertigo in adults as well as in children. The diagnostic criteria of the consensus document of the International Bárány Society for Neuro-Otology and the International Headache Society (2012) combine the typical signs and symptoms of migraine with the vestibular symptoms lasting 5 min to 72 h and exclusion criteria. Although VM accounts for 7% of patients seen in dizziness clinics and 9% of patients seen in headache clinics it is still underdiagnosed. This review provides an actual overview on the pathophysiology, the clinical characteristics to establish the diagnosis, the differential diagnosis, and the treatment of VM.

Dizziness and Orthostatic Intolerance In Pediatric Headache Patients

Children and adolescents with headaches commonly complain of dizziness that creates significant distress among the patients and their families. Dizziness is largely due to either orthostatic intolerance or vertigo; this distinction is the initial step in the evaluation of a child with co-occurrence of headaches and dizziness. Vertiginous symptoms are most commonly due to vestibular migraine or benign positional vertigo. This review would focus its attention on the diagnosis, evaluation, and management of orthostatic intolerance, specifically postural orthostatic tachycardia syndrome.

The Episodic Syndromes That Maybe Associated with Migraines

The "childhood periodic syndromes" have been renamed "the episodic syndromes that maybe associated with migraines". These syndromes were initially considered precursors of migraines that only occurred in childhood; however recent literature suggests that the episodic syndromes can occur in adults with known migraine and does not necessarily present as a precursor. This review article discusses the recent literature regarding the episodic syndromes and potential treatments. These disorders are seen by multiple subspecialists, therefore it is important to recognize and use the same definitions, criteria and nomenclature. A collaborative and multidisciplinary approach is critical to characterize, manage and potentially improve outcomes.

Functional (psychogenic) dizziness

Functional and psychiatric disorders that cause vestibular symptoms (i.e., vertigo, unsteadiness, and dizziness) are common. In fact, they are more common than many well-known structural vestibular disorders. Neurologists and otologists are more likely to encounter patients with vestibular symptoms due to persistent postural-perceptual dizziness or panic disorder than Ménière's disease or bilateral vestibular loss. Successful approaches to identifying functional and psychiatric causes of vestibular symptoms can be incorporated into existing practices without much difficulty. The greatest challenge is to set aside dichotomous thinking that strongly emphasizes investigations of structural diseases in favor of a three-pronged approach that assesses structural, functional, and psychiatric disorders simultaneously. The pathophysiologic mechanisms underlying functional and psychiatric causes of vestibular symptoms are better understood than many clinicians realize. Research methods such as advanced posturographic analysis and functional brain imaging will push this knowledge further in the next few years. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically. Diagnostic and therapeutic approaches are necessarily multidisciplinary in nature, but they are well within the purview of collaborative care teams or networks of clinicians coordinated with the neurologists and otologists whom patients consult first.

The Pediatric Vestibular Symptom Questionnaire: A Validation Study

OBJECTIVE

To develop and validate the Pediatric Vestibular Symptom Questionnaire (PVSQ) and quantify subjective vestibular symptom (ie, dizziness, unsteadiness) severity in children.

STUDY DESIGN

One hundred sixty-eight healthy children (female, n = 91) and 56 children with postconcussion dizziness or a vestibular disorder (female, n = 32), between ages 6 and 17 years, were included. The PVSQ contains questions regarding vestibular symptom frequency during the previous month. The Strengths and Difficulties Questionnaire (SDQ), a brief behavioral screening instrument, was also completed.

RESULTS

The PVSQ showed high internal consistency (10 items; Cronbach α = 0.88). A significant between-group difference was noted with higher (ie, worse) PVSQ scores for children with vestibular symptoms (P < .001); no significant differences were noted between patient groups. The optimal cut-off score for discriminating between individuals with and without abnormal levels of vestibular symptoms was 0.68 out of 3 (sensitivity 95%, specificity 85%). Emotional and hyperactivity SDQ subscale scores were significantly worse for patients compared with healthy participants (P ≤ .01). A significant relationship was noted between mean PVSQ and SDQ (parent-rated version) hyperactivity and total scores for patients (P ≤ .01) and the SDQ (self-rated) emotional, hyperactivity, and total score (P ≤ .01) in healthy controls. However, mean SDQ subscale and total scores were within normal ranges for both groups.

CONCLUSIONS

Self-reported vestibular symptoms, measured by the PVSQ, discriminated between children presenting with vestibular symptoms and healthy controls and should be used to identify and quantify vestibular symptoms that require additional assessment and management.

Cyclic vomiting syndrome versus inborn errors of metabolism: A review with clinical recommendations

BACKGROUND

Inborn errors of metabolism are on the differential for patients presenting with a cyclic vomiting syndrome phenotype. Classes of disorders to consider include: mitochondrial disorders, fatty acid oxidation disorders, urea cycle defects, organic acidurias, and acute intermittent porphyria.

AIM

This article reviews the metabolic differential diagnosis and approach to screening for inborn errors in children and adults presenting with a cyclic or recurrent vomiting phenotype.

CONCLUSION

Cyclic vomiting syndrome is thought to be an episodic syndrome that may be associated with migraine. It is a diagnosis of exclusion. Inborn errors of metabolism should be considered in the patient presenting with a recurrent vomiting phenotype. Mitochondrial dysfunction may play a role in cyclic vomiting syndrome, and true mitochondrial disorders can present with a true cyclic vomiting phenotype.

Vertigo/dizziness in pediatric emergency department: Five years’ experience

Background

Vertigo/Dizziness in childhood is not a rare cause of visits to the emergency department (ED). We analyzed a selected group with vertigo/dizziness to identify signs and symptoms that may help to guide the diagnostic approach and management.

Methods

A total of 616 children admitted for vertigo to the ED over a five-year period were retrospectively reviewed. Their medical history, clinical characteristics, laboratory and neuroimaging tests, final diagnoses and management were analyzed.

Results

Migraine and syncope were the most frequent causes. Two patients were affected by life-threatening cardiac syncope, while structural life-threatening central nervous system diseases were found in 15 patients, none of whom presented with vertigo as an isolated clinical finding.

Conclusions

Most cases of vertigo/dizziness in childhood that consist mainly of migraine and syncope are of benign origin. The prompt identification of neurological or cardiological signs or symptoms associated with vertigo in children is mandatory to rule out life-threatening conditions.

Episodic Syndromes That May Be Associated With Migraine: A.K.A. "the Childhood Periodic Syndromes"

Previously called "childhood periodic syndromes that are commonly precursors of migraine" in International Headache Classification of Headache Disorders (ICHD)-II, these disorders were renamed "episodic syndromes that may be associated with migraine" in ICHD-III beta. The specific disorders reviewed in this article include: benign paroxysmal torticollis, benign paroxysmal vertigo, abdominal migraine, and cyclical vomiting syndrome, as well as infantile colic, which was recently added under the appendix section in ICHD-III beta.

[A Retrospective Series of 77 Pediatric Patients with Vertigo at a National Center for Child Health and Development]

The evaluation and management of vertigo in children varies among institutional and medical specialties. The aim of this study was to describe the characteristics of vertigo in children presenting at a national pediatric center. Patients < 16 years old presenting with vertigo to the department of otolaryngology at a national center for child health and development from April 2004 to October 2009 were included (N = 77; 42 males and 35 females; average age, 8.7 ± 3.4 years) in this study. The most common diagnoses were vestibular migraine (VM; N = 21), benign paroxysmal vertigo (BPV; N =16), unilateral vestibulopathy (N = 12), and psychogenic vertigo (N = 8). Significant differences were observed in the frequency of the diagnoses between children aged older and younger than 7 years: BPV was most common in children < 7 years of age (p < 0.01) and VM was most common in ≥ 27 years of age (p < 0.05). Because obtaining adequate information from children for making a correct diagnosis is sometimes difficult, acquiring sufficient information from the parents is important. In addition, getting the parents to record the nystagmus during a vertigo attack with a digital camera or cellular phone can be useful because observing the nystagmus recorded on the video is helpful for making a diagnosis. Furthermore, the parents are participating in their child's care by attempting to record the attack, strengthening the relationship between the parents and the child. The incidence of psychogenic vertigo is low (less than 10%). Therefore, although physicians have recently tended to define the disorder as psychogenic when no objective abnormality is found in a patient, making a diagnosis of psychogenic vertigo is not recommended. Because vertigo can sometimes make a child anxious, delivering the correct diagnosis and treatment at the early stage is important for preventing anxiety in affected children.