Causes of dizziness and vertigo in children and adolescents

INTRODUCTION — This topic will discuss the causes of dizziness and vertigo in pediatric patients. The evaluation of dizziness and vertigo in children and adolescents and the evaluation and causes of syncope in children and adolescents are discussed separately. (See "Evaluation of dizziness and vertigo in children and adolescents" and "Emergency evaluation of syncope in children and adolescents" and "Causes of syncope in children and adolescents".)

DEFINITIONS — Dizziness describes a disturbed sense of relationship to space [1]. It is a chief complaint commonly used to describe many conditions and may occur with or without vertigo (table 1). Vertigo (dizziness with an illusion of movement or "spinning" by the patient in the room or the room about the patient) is generally separated from other causes of dizziness and imbalance [2]:

●Vertigo results from dysfunction somewhere in the vestibular system, which has both peripheral (vestibule and semicircular canals) and central nervous system (brainstem, cerebellum, and vestibulospinal tract) components. Common causes include migraine syndromes, benign paroxysmal vertigo of childhood, head trauma, motion sickness, and middle ear disease (effusion or infection). (See 'Dizziness with vertigo' below.)

●Many conditions can cause dizziness without vestibular dysfunction (pseudovertigo). Common causes include anemia, orthostatic hypotension, presyncope, pregnancy, hyperventilation, anxiety, and depression. (See 'Dizziness without vertigo (pseudovertigo)' below.)

DIZZINESS WITH VERTIGO — Patients with vertigo may describe a sensation of spinning and often display nystagmus on physical examination. The sudden onset of symptoms may represent an acute cause of vertigo or the initial presentation of a recurrent cause of vertigo. A diagnostic approach to children and adolescents with vertigo is provided in the algorithm and discussed separately (algorithm 1). (See "Evaluation of dizziness and vertigo in children and adolescents".)

The most common causes of vertigo in children are migraine headache, benign paroxysmal vertigo of childhood, and middle ear disease with intratemporal bacterial or serous labyrinthitis [3-8]. Severe traumatic brain injury and central nervous system infection are the most frequent life-threatening etiologies.

The age of the patient is also helpful in narrowing the differential diagnosis of vertigo. Children under five years of age typically have complicated otitis media, benign paroxysmal vertigo, or rarely, paroxysmal torticollis of infancy. Children under 10 years of age rarely have Meniere disease, multiple sclerosis, or benign paroxysmal positional vertigo (BPPV). In a multicenter study of causes of vertigo among children evaluated by an otolaryngologist, the most common cause of dizziness in preschool and elementary school-aged children was benign paroxysmal vertigo, while children ages 13 and older were most commonly diagnosed with vestibular migraine [9].

Differential diagnosis

Life-threatening conditions

Head trauma — Head injuries from falls, sports, and motor vehicle accidents are common among children. A fracture of the temporal bone may damage the labyrinth and classically presents with dizziness, hearing loss, and hemotympanum. A direct blow to the temporoparietal or parietooccipital regions can cause a vestibular concussion, which produces nausea, vertigo, and nystagmus in addition to the classic symptoms of a concussion. A whiplash (hyperflexion and extension) injury may injure the basilar artery, which partially supplies the labyrinth, causing spasm and producing vestibular symptoms.

Management of basilar skull fracture or basilar artery injury is performed by a neurosurgeon with pediatric expertise and is discussed separately. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures'.)

Blunt or penetrating trauma to the middle ear may disrupt the oval window where the stapes articulates with the inner ear (figure 1) and can cause a perilymph fistula. Loud sounds or pneumatic otoscopy causes true vertigo in such patients. (See "Evaluation and management of middle ear trauma", section on 'Adjacent structures' and "Sequelae of mild traumatic brain injury", section on 'Posttraumatic vertigo and dizziness'.)

Concussion may cause dizziness with or without vertigo and requires specific symptom management. (See "Concussion in children and adolescents: Management", section on 'Dizziness'.)

Central nervous system infection — Viral and bacterial infections of the central nervous system may affect the vestibular system and rarely cause symptoms of dizziness and/or vertigo [10]. Patients will usually present with additional signs and symptoms of infection such as fever, headache, neck stiffness, or mental status changes. However, any child with fever or mental status changes deserves careful evaluation to rule out these potentially serious conditions.

Treatment of central nervous system infection requires urgent empiric antimicrobial therapy that targets the suspected pathogen and, in selected patients, other therapies to prevent neurologic complications:

●(See "Bacterial meningitis in children: Dexamethasone and other measures to prevent neurologic complications" and "Bacterial meningitis in children older than one month: Treatment and prognosis", section on 'Empiric therapy'.)

●(See "Viral meningitis in children: Management, prognosis, and prevention".)

●(See "Acute viral encephalitis in children: Treatment and prevention".)

Intracranial tumor or abscess — Although vertigo is a rare presenting sign in patients with a space-occupying brain lesion, any mass in or around the fourth ventricle or central vestibular system may cause dizziness, vertigo, or nystagmus due to compression, displacement, or localized inflammation of the brain. The symptoms typically worsen with changes in head position. (See "Clinical manifestations and diagnosis of central nervous system tumors in children", section on 'Clinical manifestations'.)

The management of central nervous system tumors in children and the treatment of bacterial brain abscess are provided separately. (See "Overview of the management of central nervous system tumors in children" and "Treatment and prognosis of bacterial brain abscess".)

Stroke — Strokes in children most commonly present with hemiplegia or altered mental status (see "Ischemic stroke in children: Clinical presentation, evaluation, and diagnosis", section on 'Clinical presentation'). However, symptoms of dizziness and/or vertigo may occur if the injury occurs in the area of the basilar artery, which partially supplies the labyrinth, the vestibular nuclei of the brainstem, or in vessels that supply any of the vestibular centers in the cortex.

The management of ischemic stroke in children is discussed separately. (See "Ischemic stroke in children: Management and prognosis".)

Drug overdose and other poisons — Use of certain recreational drugs may cause vertigo and nystagmus, including barbiturates, ethanol, ketamine, and phencyclidine. Behavioral changes and/or altered mental status usually accompany intoxication with these agents. With the exception of ketamine, rapid testing is available to establish the diagnosis. Ketamine poisoning is diagnosed based upon clinical findings and clinical course. For all of these intoxications, treatment is supportive:

●(See "Barbiturate (phenobarbital) poisoning".)

●(See "Ethanol intoxication in children: Clinical features, evaluation, and management".)

●(See "Ketamine poisoning".)

●(See "Phencyclidine (PCP) intoxication in children and adolescents".)

Common conditions

Otitis media — Otitis media is the most common cause of vestibular disturbances in children [2]. Between 60 and 80 percent of infants have at least one episode of acute otitis media by one year of age, and 80 to 90 percent by two to three years. An acute episode of otitis media (serous or suppurative) can rarely be complicated by labyrinthitis and cause dizziness, vertigo, and/or hearing loss. The diagnosis of acute otitis media is made by characteristic findings on ear examination, including tympanic membrane erythema and bulging with physical signs of middle ear effusion (picture 1). Treatment is discussed separately. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Complications of AOM' and "Acute otitis media in children: Treatment".)

Complications of otitis media that may also cause vertigo include coalescent mastoiditis and serous or suppurative labyrinthitis. Cholesteatoma can cause vestibular symptoms, especially if it erodes the bony labyrinth. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Complications' and "Cholesteatoma in children" and "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Migraine syndromes — Migrainous vertigo is a term used to describe episodic vertigo in patients with a history of migraines or with other clinical features of migraine. Unlike adults, who generally present with headache, children may present with other manifestations of migraine, such as vertigo with nystagmus, and frequently have no associated headache. In addition, up to 19 percent of children with classic migraine have vertiginous symptoms during their aura. (See "Vestibular migraine", section on 'Clinical features'.)

Basilar artery migraines, which are most common before the age of 20 years, present with two or more basilar-type aura symptoms including vertigo. Symptoms resolve within two hours and are usually followed by a throbbing headache (table 2). (See "Migraine with brainstem aura".)

For the first acute episode, the major consideration for patients with vestibular or basilar migraine is to differentiate either condition from a stroke, which may warrant consultation with a pediatric neurologist and neuroimaging. Once stroke is excluded, then abortive therapy, typically in consultation with a pediatric neurologist, may be provided. For patients with a history of vestibular or basilar artery migraine, if the episode is typical of prior episodes, the clinician may go directly to pharmacologic therapy. (See "Acute treatment of migraine in children".)

Benign paroxysmal vertigo of childhood — Benign paroxysmal vertigo (BPV) is a disorder of early childhood manifested by recurrent episodes of brief disequilibrium. During the attacks, the child appears frightened and off balance, often reaching out to steady him or herself. The events may be associated with nystagmus, diaphoresis, nausea, and vomiting. Older children will grab nearby persons or furniture for support to prevent falling and may complain of vertigo or dizziness. Episodes usually last less than a minute and are not associated with altered consciousness. They usually recur in clusters, occurring daily for several days in a row, remitting for several weeks, and recurring again. A family history of migraine headaches is frequently present. The neurologic examination is normal between episodes, and there are no specific laboratory tests that have been useful in establishing the diagnosis of BPV. The diagnosis is typically made by history alone. The disorder typically remits spontaneously by five years of age. Many patients subsequently develop typical migraine headaches. There is no specific treatment that has been shown to prevent the episodes. Differentiation from seizures is an important consideration. (See "Nonepileptic paroxysmal disorders in children", section on 'Benign paroxysmal vertigo'.)

Unlike other causes of nystagmus, patients with benign paroxysmal vertigo of childhood have normal eye and neurologic examinations between episodes. (See "Pendular nystagmus".)

Adverse effects of medications — A large number of medications list dizziness as a possible side effect. Several affect the labyrinth and may cause dizziness with vertigo, including aminoglycosides, furosemide, minocycline, and salicylates. Of these, aminoglycosides are best established as potentially toxic to the peripheral vestibular system. These effects may be heightened in patients with genetic predisposition. Efforts to prevent toxicity include substitution of other antibiotics whenever feasible and, in patients who do require aminoglycoside therapy, careful monitoring of drug levels, proper adjustment for decreased renal function, daily dosing, limiting duration of treatment, and minimizing co-administration of other ototoxic drugs. (See "Pathogenesis and prevention of aminoglycoside nephrotoxicity and ototoxicity".)

The adverse effects of quinine and quinidine include a complex of symptoms referred to as cinchonism: tinnitus, nausea, headaches, dizziness, and disturbed vision. These symptoms do not warrant change in drug dose. However, toxicity often interferes with compliance in completing the course of therapy. (See "Antimalarial drugs: An overview", section on 'Quinine and quinidine'.)

Medications known to induce downbeat nystagmus, which may be mistakenly attributed to vertigo, include carbamazepine, lithium, and phenytoin. (See "Jerk nystagmus", section on 'Etiology'.)

Motion sickness — Motion sickness is caused by a mismatch between visual, vestibular, and somatosensory cues provided to the brain. As an example, if the visual system indicates that a person is stationary (eg, viewing the interior of a cabin on a ship), but the vestibular system senses ongoing head movements (eg, due to motion of the ship), the vestibular and visual cues conflict and engender symptoms of motion sickness. Furthermore, if the semicircular canals and otolith organs produce sensory cues that are incongruous, motion sickness can be evoked that is independent of vision. Common symptoms include pallor, diaphoresis, dizziness, nausea, and vomiting; and usually occur during travel in a boat, car, or airplane. It is much more common in children who have migraines compared with those without. However, a sensation of spinning is rare. (See "Motion sickness".)

The management of motion sickness is discussed separately. (See "Motion sickness", section on 'Approach to management'.)

Vestibular neuritis — Vestibular neuritis, also known as vestibular neuronitis, represents an acute, spontaneous, peripheral vestibular ailment, characterized by the rapid onset of severe vertigo with nausea, vomiting, and gait instability. Vestibular neuritis is a common cause of vertigo in adults but is rare in children. Patients prefer to lie still with the affected ear facing up. There is no associated hearing loss. It is thought to be due to a postinfectious inflammation or viral infection of the vestibular nerve, with mumps, measles, Epstein-Barr virus, and herpesvirus being known pathogens. However, a history of a recent viral infection is present in less than half of patients. Symptoms may last from weeks to months. (See "Vestibular neuritis and labyrinthitis".)

Labyrinthitis, a specific type of vestibular neuritis, presents with the sudden onset of hearing loss and vertigo. It is caused by a viral or bacterial infection of the labyrinth and may occur alone or as a complication of otitis media or meningitis. Hearing loss may be permanent.

The management of vestibular neuritis and labyrinthitis is provided separately. (See "Vestibular neuritis and labyrinthitis", section on 'Treatment'.)

Other conditions — Less common etiologies of dizziness with vertigo warrant early involvement of a specialist (pediatric neurologist or otolaryngologist):

●Benign paroxysmal positional vertigo – BPPV is rare in children but has been reported in the literature in a patient as young as three years old [11]. Patients typically complain of vertigo with changes in head position, especially upon waking in the morning and sitting up in bed. Episodes usually last less than one minute. The symptoms can be elicited by the Dix-Hallpike (or Nylen-Barany) maneuver, in which the neck is extended and turned to one side before the patient is placed supine rapidly (figure 2). In patients with BPPV, nystagmus should occur within 30 seconds. (See "Benign paroxysmal positional vertigo", section on 'Response to provoking maneuvers' and "Benign paroxysmal positional vertigo", section on 'Symptoms'.)

●Paroxysmal torticollis of infancy – Paroxysmal torticollis is a benign, self-limited condition characterized by recurrent episodes of head tilt often accompanied by vomiting, pallor, irritability, ataxia, or drowsiness that usually presents in the first few months of life. The periodic episodes of torticollis can randomly alternate from side to side. The individual attacks typically last for hours but occasionally last for days. The episodes occur less frequently as the child gets older and disappear in most cases by five years of age. The pathogenesis of benign paroxysmal torticollis has not been determined. It is considered to be a "migraine equivalent" disorder. Some patients go on to develop migraine headaches or benign paroxysmal vertigo. (See "Acquired torticollis in children", section on 'Benign paroxysmal torticollis'.)

Paroxysmal torticollis of infancy has findings that are similar to spasmus nutans; however, unlike patients with paroxysmal torticollis, children with spasmus nutans typically have head nodding and strabismus with amblyopia. In addition, patients with spasmus nutans do not go on to develop migraine headaches. (See "Pendular nystagmus", section on 'Spasmus nutans'.)

●Meniere disease – The clinical features of Meniere disease consist of fullness in the affected ear, tinnitus, vertigo, and fluctuating unilateral sensorineural hearing loss. Episodes may be accompanied by autonomic symptoms such as pallor, nausea, and vomiting. Meniere disease is associated with endolymphatic hydrops with distortion and distention of the membranous, endolymph-containing portions of the labyrinthine system. Meniere disease can begin at any age, but patients typically present with symptoms between the ages of 20 and 40. Meniere syndrome in children is most often associated with congenital malformations of the inner ear, some of which are discussed separately. (See "Meniere disease: Evaluation, diagnosis, and management".)

●Perilymphatic fistula – A perilymphatic fistula is an abnormal connection between the inner and middle ear. It may be congenital, causing permanent sensorineural hearing loss, or acquired. Acquired causes include barotrauma (from diving, descending in an airplane that is not well pressurized, sneezing, coughing, or any sudden change in pressure in the middle ear), head injury, middle ear trauma, and middle ear infection. The diagnosis is suggested by sudden or fluctuating hearing loss accompanied by dizziness or vertigo. Symptoms should worsen with changes in middle ear pressure and may be elicited by pneumatic otoscopy, having the patient Valsalva (positive Hennebert's sign), or Tullio phenomenon (vertigo and nystagmus in response to a loud sound). (See "Complications of SCUBA diving", section on 'Ear barotrauma' and "Evaluation and management of middle ear trauma", section on 'Adjacent structures'.)

●Seizures – Seizures, while common in children, do not often present with true vertigo. Two kinds of seizures involve the vestibular system. Vestibular seizures are characterized by the sudden onset of vertigo followed by a loss of consciousness or postictal state. Vestibulogenic seizures are seizures induced by stimulating the vestibular system via sudden rotation or caloric testing (see "Evaluation of dizziness and vertigo in children and adolescents", section on 'Tests of vestibular function'). The electroencephalogram will be abnormal in both cases [12]. Treatment is best guided by a pediatric neurologist.

●Ramsay Hunt syndrome – Ramsay Hunt syndrome (Herpes zoster oticus) arises from Varicella-zoster reactivation with Herpes zoster infection of the ear canal. Clinical manifestations include auricular and auditory canal vesicles, facial paralysis, and ear pain. Vertigo is also frequently reported and occurs when the herpesvirus affects the eighth cranial nerve, causing symptoms of vestibular neuritis. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'Ramsay Hunt syndrome (herpes zoster oticus)'.)

●Multiple sclerosis — Multiple sclerosis is most commonly seen in young women and is rare in children. Vertigo is a reported symptom in 30 to 50 percent of patients with multiple sclerosis. It is commonly associated with symptoms reflecting dysfunction of adjacent cranial nerves such as hyper- or hypoacusis, facial numbness, and diplopia. (See "Manifestations of multiple sclerosis in adults", section on 'Vertigo'.)

●Enlarged vestibular aqueduct syndrome – This congenital anomaly of the inner ear is associated with a vestibular aqueduct >1.5 millimeters, sensorineural or mixed hearing loss, and vertigo [13,14].

DIZZINESS WITHOUT VERTIGO (PSEUDOVERTIGO) — A variety of conditions may produce subjective feelings of dizziness without vertigo (pseudovertigo) that correspond to presyncope or nonspecific "lightheadedness" (table 1). The history, physical examination, and limited ancillary testing will often point to an underlying cause, especially in children with presyncope (algorithm 2) or ataxia (algorithm 3) as discussed separately. (See "Emergency evaluation of syncope in children and adolescents" and "Approach to the child with acute ataxia".)

Of these, potentially life-threatening causes include cardiac arrhythmias, hypoglycemia, heat stroke, or serious poisoning or adverse effects of medication. These and other causes are discussed in greater detail separately. (See "Causes of syncope in children and adolescents".)

Patients with dizziness from acute disequilibrium rather than vertigo warrant careful evaluation for serious causes of ataxia, which vary by age, and often warrant additional testing and consultation with a pediatric neurologist (table 3). (See "Approach to the child with acute ataxia".)

Cerumen impaction may cause dizziness with unilateral hearing loss. Cerumen varies widely in appearance and texture from almost liquid to rock hard. Appearance may depend on the percentage of its different components, time spent in the ear canal (harder cerumen is usually present for longer periods of time), and the amount of desquamated skin. Color ranges from a deep, dark red to black to off-white. Cerumen removal is curative. (See "Cerumen".)

SUMMARY AND RECOMMENDATIONS

●Definition – Dizziness describes a disturbed sense of relationship to space. It is a chief complaint commonly used to describe many conditions and may occur with or without vertigo (table 1). Vertigo (dizziness with an illusion of movement or "spinning" by the patient in the room or the room about the patient) arises from vestibular dysfunction. (See 'Definitions' above.)

●Causes of dizziness with vertigo – Most children or adolescents with dizziness and vertigo will have benign paroxysmal vertigo of childhood, or a migraine syndrome as an underlying cause. However, patients with head trauma, altered mental status, focal neurologic findings, or evidence of central nervous system infection or inflammation warrant neuroimaging and additional evaluation (algorithm 1). (See 'Common conditions' above and "Evaluation of dizziness and vertigo in children and adolescents".)

●Pseudovertigo – A variety of conditions may produce subjective feelings of dizziness without vertigo (pseudovertigo) that correspond to presyncope or nonspecific "lightheadedness". The history, physical examination, and limited ancillary testing will often point to an underlying cause, especially in children with presyncope (algorithm 2) or ataxia (algorithm 3) as discussed separately. (See "Emergency evaluation of syncope in children and adolescents" and "Approach to the child with acute ataxia".)

Potentially life-threatening causes of dizziness without vertigo include cardiac arrhythmias, hypoglycemia, heat illness, serious poisoning, or adverse effects of medication. (See 'Dizziness without vertigo (pseudovertigo)' above.)