Evaluation of dizziness and vertigo in children and adolescents

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

EPIDEMIOLOGY — The overlapping complaints of dizziness with vertigo, balance problems, lightheadedness, fainting, unsteadiness, and clumsiness have an estimated prevalence of about 5 percent in children and adolescents [1-3]. Based upon reports from specialty clinics, benign paroxysmal vertigo, vestibular migraine, and head trauma comprise the final diagnosis in about 50 percent of patients [4]. Middle ear disease (effusion or infection) and motion sickness are other common etiologies. Life-threatening etiologies, such as a brain tumor, stroke, or meningitis, are rare causes of vertigo in children and adolescents [4].

Dizziness without vertigo is a vague symptom that can be caused by many conditions. It may occur in patients with faintness, lightheadedness, or unsteadiness caused by hypoglycemia, presyncope (orthostatic hypotension), anemia, heat illness, anxiety with hyperventilation, intoxication, pregnancy, and, rarely, ataxia or visual disturbance from central nervous system abnormalities.

DEFINITIONS — Dizziness describes a disturbed sense of relationship to space [5]. 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 [6]:

●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 "Causes of dizziness and vertigo in children and adolescents", section on 'Dizziness with vertigo'.)

●Many conditions can cause dizziness without vestibular dysfunction (pseudovertigo). Common causes include anemia, orthostatic hypotension, presyncope, pregnancy, hyperventilation, anxiety, and depression. (See "Causes of dizziness and vertigo in children and adolescents", section on 'Dizziness without vertigo (pseudovertigo)'.)

CLINICAL ANATOMY — The semicircular canals and vestibule (together known as the labyrinth) make up the peripheral vestibular system and are located within the inner ear, adjacent to the cochlea in the petrous portion of the temporal bone (figure 1). These organs send impulses to the central components of the vestibular system, located in the brainstem, cerebellum, and cortex, via the eighth cranial nerve (figure 2). Efferent impulses travel through the vestibulospinal tract to the peripheral muscles and also within the medial longitudinal fasciculus to cranial nerves III, IV, and VI. Cranial nerve VIII (vestibulocochlear nerve) is responsible for both hearing and vestibular function. A disturbance anywhere in the vestibular system may cause patients to have vertigo and associated signs and symptoms such as hearing loss, perceptual changes in vision (eg, blurry vision), and nystagmus.

CAUSES — The differential diagnosis of a complaint of vertigo or dizziness depends on whether the patient has dizziness with vertigo or dizziness without vertigo (pseudovertigo) (table 1). For children with vertigo, this differentiation requires the performance of a careful physical examination, including various maneuvers to elicit nystagmus. For immediate consideration, life-threatening causes of dizziness with vertigo include central nervous system infection, head trauma, poisoning or adverse medication effect, stroke, and brain tumor. For dizziness without vertigo, life-threatening considerations include arrhythmia, heat illness, hypoglycemia, and poisoning or adverse medication effect. The causes of dizziness and vertigo in children is discussed in greater detail separately. (See "Causes of dizziness and vertigo in children and adolescents".)

EVALUATION

Initial stabilization — Patients with vertigo and altered mental status require rapid assessment and support of airway, breathing, and circulation and determination of a rapid blood glucose (see "Evaluation of stupor and coma in children"). Patients with significant head injury also require appropriate trauma assessment and stabilization as discussed separately. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management" and "Trauma management: Approach to the unstable child".)

Children with fever and signs of meningitis or encephalitis (eg, meningismus and/or altered mental status) may present with respiratory or hemodynamic instability and may require airway management (table 2) and/or treatment of septic shock according to the 2020 Surviving Sepsis Campaign International Guidelines for the management of septic shock and sepsis-associated organ dysfunction in children (algorithm 1). (See "Bacterial meningitis in children older than one month: Treatment and prognosis", section on 'Empiric therapy' and "Acute viral encephalitis in children: Treatment and prevention", section on 'Empiric antimicrobial therapy'.)

Vertigo versus other dizziness — When evaluating children with dizziness, the clinician must first distinguish vertigo from other forms of dizziness. However, this task can be difficult. Patient description, augmented by caregiver history, is essential to correct categorization. Classically, vertigo has been differentiated from other causes of dizziness (eg, presyncope, nonspecific dizziness, or disequilibrium) by the presence of a "spinning" sensation; patients may also use terms such as "whirling," "tilting," or "moving." However, younger children often cannot accurately describe what they are experiencing, and older children may not describe their vertigo in such vivid terms. In addition, vague dizziness, imbalance, or disorientation can be caused by vestibular pathology. Furthermore, some patients without vertigo may describe a spinning sensation during episodes of presyncope or nonspecific dizziness.

In individuals with a history that suggests vertigo, physical examination should focus on oculomotor signs (especially the presence of nystagmus), hearing, balance, gait, and the presence of focal neurologic findings to determine whether vestibular dysfunction is present and, if so, to localize the etiology to a peripheral or central vestibular abnormality (table 3) (see 'Vertigo' below). Specialty consultation and provocative vestibular testing is indicated when the presence of vertigo is suspected but can't be established by history and physical examination or when there is clinical suspicion for central vertigo.

Dizziness without vertigo is a frequent complaint in children and adolescents and can be due to a variety of etiologies. In many patients, a careful history and physical examination with selected ancillary studies can identify the underlying cause. (See 'Dizziness without vertigo (pseudovertigo)' below.)

History — History is often the essential part of the evaluation that identifies the presence of vertigo and distinguishes it from other forms of dizziness. In young children who cannot describe what they are experiencing, vomiting, irritability, desire to lay still, a history of gait disturbance with falling, or eye twitching (nystagmus) may be findings of vertigo. In older patients, the symptom of "spinning" should be evaluated in the context of all other clinical features to correctly identify the presence of vertigo versus other types of dizziness.

Characteristic findings of vertigo in children include:

●Acute and episodic rather than continuous symptoms – Vertigo tends to have an acute onset with a self-limited episode of a few days. It is unusual for it to be continuous for more than a few weeks. Even when the vestibular lesion is permanent, the central nervous system adapts to the defect so that vertigo typically subsides over several weeks. A history of recurrent episodes of vertigo suggests migraine headache or any of its variants (eg, benign paroxysmal vertigo of childhood, motion sickness, or paroxysmal torticollis of infancy). Less common causes of episodic vertigo include seizures, perilymphatic fistula, Meniere disease, or benign paroxysmal positional vertigo (BPPV). (See "Causes of dizziness and vertigo in children and adolescents", section on 'Dizziness with vertigo'.)

●Nausea and vomiting – Nausea and vomiting are typical features of acute vertigo, unless it is mild or very brief (as with BPPV). In addition to headache and aura, vomiting may also be a prominent feature of a vestibular migraine. Vomiting can be severe, causing dehydration and electrolyte imbalance. Emesis commonly accompanies vertigo from peripheral causes. However, vomiting associated with meningismus, ataxia, or other cranial nerve abnormalities (eg, facial weakness, visual disturbance) suggests increased intracranial pressure associated with a central nervous system tumor, abscess, or infection.

●Precipitating factors – Important aggravating or provoking factors suggestive of vertigo or types of vertigo include:

•Head motion and position – Most vertigo is made worse by moving the head. This is a useful feature for distinguishing vertigo from other forms of dizziness. Many children in the midst of a vertiginous attack are greatly distressed by head motion and lie very still. If head motion does not worsen the symptom, it is probably another type of dizziness rather than vertigo.

Dizziness with standing or arising from sleep may be caused by positional vertigo or postural presyncope. Positional vertigo is also provoked when rolling over in bed or lying down, which helps to differentiate it from postural presyncope. (See "Causes of dizziness and vertigo in children and adolescents", section on 'Other conditions'.)

•Preceding head or middle ear trauma – Head or middle ear trauma may result in injury to peripheral or central components of the vestibular system. However, dizziness without vestibular injury is also a common component of concussion in children. (See "Causes of dizziness and vertigo in children and adolescents", section on 'Other conditions'.)

•Change in middle ear pressure – Coughing, sneezing, or Valsalva maneuvers can provoke vertigo in patients with a perilymphatic fistula. (See "Causes of dizziness and vertigo in children and adolescents", section on 'Other conditions'.)

•Occurring during or soon after car, boat, or airplane travel – Dizziness accompanied by pallor, diaphoresis, nausea, and/or vomiting after travel points to motion sickness or, specifically with airplane travel, to perilymphatic fistula. (See "Causes of dizziness and vertigo in children and adolescents", section on 'Motion sickness' and "Causes of dizziness and vertigo in children and adolescents", section on 'Other conditions'.)

Other historical findings that help identify the underlying cause of vertigo include:

●Fever – A history of fever points toward infection of the ear or central nervous system.

●Altered mental status – Mental status changes may occur with meningitis, encephalitis, intracranial abscess, seizures (postictal state), stroke, tumor, or ingestion. (See "Evaluation of stupor and coma in children".)

●Possible poisoning (young child) or use of recreational drugs (older child or adolescent) – Any medications in the household should be noted as they could be possible ingestants. Older children and adolescents should be privately questioned about recreational substance use, especially ethanol, barbiturates, ketamine, and phencyclidine, which can cause nystagmus and vertigo. (See "Causes of dizziness and vertigo in children and adolescents", section on 'Drug overdose and other poisons'.)

●Symptoms of brainstem pathology – Symptoms such as staggering or ataxic gait, vomiting, headache, double vision, visual loss, slurred speech, numbness of the face or body, weakness, clumsiness, or incoordination suggest a posterior fossa process, such as a central nervous system tumor, infection, or inflammation; or a vertebral dissection causing a posterior stroke. (See "Clinical manifestations and diagnosis of central nervous system tumors in children" and "Ischemic stroke in children: Clinical presentation, evaluation, and diagnosis".)

●Hearing loss – Decreased hearing may occur with temporal bone fracture, otitis media, labyrinthitis, Meniere disease, perilymphatic fistula, processes that may impinge on cranial nerve VIII, and some medications (eg, aminoglycosides. furosemide, minocycline, and salicylates).

●Recent upper respiratory tract infection – Viral infection may precede vestibular neuritis or otitis media.

●Recurrent episodes of otitis media – Recurrent otitis media may be associated with mastoiditis or suppurative labyrinthitis and vertigo.

●Current medications – Many medications list dizziness as a possible side effect. Several affect the labyrinth and may cause dizziness with vertigo, including aminoglycosides, furosemide, minocycline, and salicylates.

●A past medical history of recurrent headaches in the patient or family members – In children with vertiginous migraines, vertigo may be the sole finding and headache may not be present. (See "Migraine with brainstem aura".)

Other symptoms that patients may identify as dizziness include presyncopal faintness, disequilibrium, and nonspecific or ill-defined lightheadedness:

●Presyncope – Presyncope is the prodromal symptom of fainting or a near faint. Presyncope occurs more commonly than syncope. It usually lasts for seconds to minutes and is often recognized by the patient as "nearly blacking out" or "nearly fainting." When the symptoms are less intense, their description may be less clear. Patients may also report lightheadedness, a feeling of warmth, diaphoresis, nausea, and visual blurring occasionally proceeding to blindness. An observation of pallor and decreased responsiveness by onlookers also supports presyncope. Presyncope usually occurs when the patient is standing or seated upright and not when supine (if the latter, one should suspect a cardiac arrhythmia rather than hypotension). Evaluation of presyncope is the same as for syncope and is discussed separately. (See "Emergency evaluation of syncope in children and adolescents".)

●Disequilibrium – Disequilibrium refers to unsteadiness with walking. Disequilibrium may occur in children with concussion, peripheral neuropathy (eg, Guillain-Barré), or acute cerebellar ataxia; or after recreational use of substances such as ethanol and benzodiazepines. 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 4). (See "Approach to the child with acute ataxia".)

●Nonspecific dizziness (lightheadedness) – Nonspecific dizziness is often difficult for the patient to describe. They may simply insist, "I am dizzy." Patients may choose from suggested descriptions to say they are "giddy" or "lightheaded"; however, they may also endorse a fainting or spinning sensation. Nonspecific dizziness may accompany mild presyncope or vertigo, mild head trauma (concussion) or whiplash injuries, hypoglycemia, and exposure to anticholinergic agents (eg, antihistamines, atropine, or cyclic antidepressants), carbon monoxide, and benzodiazepines.

Hyperventilation, depression, or anxiety are important causes of or contributing factors for dizziness. Individuals with manifestations of anxiety or depression during evaluation may warrant formalized assessment. (See "Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course" and "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis".)

Physical examination — In addition to performing a complete physical examination, the clinician should pay special attention to vital signs, ear findings, nystagmus, other vestibular signs, and any neurologic abnormalities.

Vital signs — Fever suggests an infectious cause of vertigo. Hypertension with tachycardia or bradycardia implies increased intracranial pressure due to head trauma or a space-occupying intracranial process. Ketamine and phencyclidine intoxication can cause hypertension, tachycardia, and vertigo. Bradycardia, hypotension, and vertigo may occur after ethanol or barbiturate poisoning.

Orthostatic changes may suggest presyncope as the underlying cause, especially if dizziness occurs during testing. Of note, orthostatic changes are neither sensitive nor specific in children, and, in isolation, such changes cannot rule out or confirm presyncope as an underlying cause.

Ocular nystagmus — Ocular nystagmus is the most common physical manifestation of vertigo. Key features of the nystagmus include its type (horizontal, torsional, vertical), its tendency to suppress with visual fixation, and whether or not its direction alters with gaze position. Careful assessment can suggest central versus peripheral vestibular pathology (table 3). Evaluation of nystagmus is discussed in more detail separately. (See "Evaluation of the patient with vertigo", section on 'Nystagmus'.)

Ear examination — The ear examination is important to identify conditions that can cause peripheral vertigo:

●Tympanic membrane erythema, bulging, or decreased mobility in association with middle ear effusion (picture 1) (otitis media).

●Protrusion of the auricle accompanied by swelling, erythema, and tenderness of the mastoid (picture 2 and picture 3) (mastoiditis).

●Hemotympanum (picture 4), otorrhea, tympanic membrane perforation (picture 5), and/or disruption of the ossicles (temporal bone fracture and/or middle ear injury).

●Hearing loss (otitis media, mastoiditis, middle ear trauma, labyrinthitis). A discussion of hearing tests that can be simply performed in the ambulatory setting is provided separately. (See "Evaluation of the patient with vertigo", section on 'Office hearing tests'.)

●Vertigo and nystagmus following a loud noise (Tullio phenomenon) or with pneumatic otoscopy of an intact tympanic membrane (perilymphatic fistula).

●Deep retraction pocket (picture 6) or white mass behind the tympanic membrane (picture 7) (cholesteatoma).

●Vesicles on the auricle or in the auditory canal (Ramsay Hunt syndrome [herpes zoster infection of the ear canal]).

Neurologic examination — Altered mental status may be seen in patients with central nervous system infection, increased intracranial pressure, or poisoning. A careful neurologic examination should be performed because the presence of additional neurologic abnormalities also strongly suggests the presence of a central lesion. A search should be made for cranial nerve abnormalities, motor or sensory changes, dysmetria, or abnormal reflexes.

Unilateral peripheral vestibular disorders (eg, benign paroxysmal vertigo, otitis media with labyrinthitis, middle ear trauma, cholesteatoma, or vestibular neuritis) generally cause patients to lean or fall toward the side of the lesion. Children may be uncomfortable and reluctant to move because of their vertigo, but they are still able to walk. Romberg testing will demonstrate falling or tilting to one side.

Patients with an acute cerebellar lesion (eg, posterior fossa tumor) are often unable to walk without falling. The direction of tilting or falling with Romberg testing may vary. (See "Approach to the child with acute ataxia".)

While the ability to walk and the direction of falling may provide useful clues to the origin of vertigo, in practice, it may be difficult to persuade a patient with severe vertigo to attempt to walk.

Tests of vestibular function — Patients in whom vertigo is suspected based upon routine physical examination warrant further evaluation of vestibular function. When physical examination testing is equivocal, consultation with a pediatric neurologist or otolaryngologist is warranted. If there is high suspicion for cerebellar dysfunction, then neuroimaging, preferably magnetic resonance imaging (MRI), should be performed.

The head impulse test (or head thrust test) may be helpful for distinguishing vestibular dysfunction from nonvestibular dizziness. The test is performed by instructing the patient to keep his or her eyes on a distant target. If needed, the patient should wear his or her usual prescription eyeglasses. The head is then turned approximately 15° quickly and unpredictably by the examiner. The normal response is that the eyes remain on the target. The abnormal response is that the eyes are dragged off of the target by the head turn (in one direction), followed by a saccade back to the target after the head turn (figure 3); this response indicates a deficient vestibuloocular reflex on the side of the head turn, implying a peripheral vestibular lesion (inner ear or vestibular nerve) on that side. In general, the test is more specific than it is sensitive. (See "Evaluation of the patient with vertigo", section on 'Head impulse test'.)

Evaluation of static and dynamic vestibular function can assist in differentiating vertigo from central versus peripheral vestibular system causes but requires patient cooperation. Some tests of vestibular function are described separately. (See "Evaluation of the patient with vertigo", section on 'Other vestibular signs'.):

●Tests of static vestibular imbalance:

•Skew deviation – Vertical misalignment of the eyes.

•Ocular tilt reaction (head tilt) – Children with skew deviation may accommodate by characteristic positioning of the head and eyes.

•Tilt of the subjective visual vertical – Patient perception of vertical does not match true gravitational vertical (picture 8).

●Tests of dynamic vestibular imbalance:

•Head-shaking visual acuity – Comparison of visual acuity with head still versus continuously shaking back and forth over a small range of motion at approximately two movements per second (2 Hz).

•Head-shaking nystagmus – Head-shaking nystagmus is elicited by the patient shaking the head from side to side for 15 to 40 seconds with eyes closed. Nystagmus on opening the eyes suggests a central vestibular lesion.

●The Dix-Hallpike (or Nylen-Barany) maneuver (figure 4), which tests for BPPV (rare in children).

●Caloric testing – Caloric testing is distressing to the child and may cause nausea and vomiting. It is rarely performed in the emergency department or office setting but may be used by vestibular specialists. It is performed by infusing warm or cold water into the ear. Otoscopy should first be performed to ensure that cerumen is not obstructing the flow of water to the tympanic membrane and to verify that there is no tympanic membrane perforation. (See "Evaluation of the patient with vertigo", section on 'Other vestibular signs'.)

Ancillary studies — Further evaluation depends upon whether vertigo is present:

Dizziness with vertigo — In patients with vertigo, additional evaluation is dictated by the history and physical examination. Neuroimaging is indicated for patients with a history of trauma (computed tomography [CT] of the head with temporal bone windows) or patients with evidence of central vestibular abnormalities, altered mental status, or associated focal neurologic findings (MRI of the brain or multimodal head CT) (algorithm 2).

Once increased intracranial pressure is excluded by physical examination or neuroimaging, lumbar puncture should be performed in patients with suspected meningitis, encephalitis, or multiple sclerosis. In patients with a suspicion of seizures, an electroencephalogram should be arranged.

Other specialized vestibular testing (eg, videonystagmography, rotary chair testing, posturography, and audiometry) is indicated when central versus peripheral vertigo cannot be established, hearing loss is present on examination, or when vertigo is prolonged or incapacitating. These tests are usually performed by a pediatric neurologist or otolaryngologist. (See "Evaluation of the patient with vertigo", section on 'Diagnostic tests'.)

Dizziness without vertigo — In children and adolescents who report dizziness without signs of vertigo, further testing varies by clinical findings:

●Presyncope – The approach to testing of children with symptoms of near-fainting (presyncope) is the same as for syncope and should be guided by history and examination findings. Patients with loss of consciousness warrant additional evaluation, as discussed in detail separately. (See "Emergency evaluation of syncope in children and adolescents".):

●Disequilibrium – Dizziness and unsteadiness with walking are common features of acute ataxia or concussion. Patients with acute ataxia and altered mental status warrant a rapid blood glucose and testing for possible drug intoxication (eg, benzodiazepines, cannabinoids, anticonvulsants, ethanol, or opioids). Urgent neuroimaging is indicated for patients with a history of head or neck trauma, signs or symptoms of increased intracranial pressure, focal neurologic findings, or fever with meningismus. (See "Approach to the child with acute ataxia".)

Disequilibrium may not warrant any further testing in children or adolescents with a history of mild head injury and typical signs and symptoms of concussion, especially if there was no history of loss of consciousness. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis".)

●Nonspecific dizziness – Individuals with nonspecific lightheadedness may warrant further testing based on history and physical examination.

DIAGNOSTIC APPROACH — The presence or absence of vertigo guides the diagnostic approach and helps identify the likely underlying cause (table 1).

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 (algorithm 2).

Patients with vertigo and a history of trauma should undergo a CT of the head with temporal bone windows. Those with mental status changes or an abnormal neurologic examination also warrant neuroimaging (MRI or CT). Patients with fever and other signs of meningitis or encephalitis should undergo lumbar puncture as long as increased intracranial pressure is excluded by physical examination and/or neuroimaging.

Any history of hearing loss or otologic abnormalities should be noted. Other helpful historical details include any recent upper respiratory infections and a family history of migraines. Patients with vertigo and no findings on physical examination warrant prompt referral to a neurologist or otolaryngologist for advanced vestibular testing if symptoms are prolonged or severe.

Dizziness without vertigo (pseudovertigo) — Patients with dizziness but no physical findings of vestibular dysfunction may describe a wide variety of symptoms but will lack signs and symptoms of vestibular dysfunction. The history, physical examination, and limited ancillary testing will often point to an underlying cause, especially in children with presyncope (algorithm 3) or ataxia (algorithm 4). (See "Emergency evaluation of syncope in children and adolescents" and "Approach to the child with acute ataxia".)

MANAGEMENT — Successful management of dizziness consists of accurately diagnosing and treating the underlying cause as briefly described separately with links to detailed management discussions. (See "Causes of dizziness and vertigo in children and adolescents".)

SUMMARY AND RECOMMENDATIONS

●Definitions – 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.)

●Emergencies – Patients with vertigo and altered mental status require rapid assessment and support of airway, breathing, and circulation and determination of a rapid blood glucose. (See 'Initial stabilization' above.)

●History – History can identify the presence of vertigo and distinguishes it from other forms of dizziness (eg, presyncope, disequilibrium, or nonspecific dizziness).

In young children who cannot describe what they are experiencing, vomiting, irritability, desire to lay still, a history of gait disturbance with falling, or eye twitching (nystagmus) may be findings of vertigo.

•In older patients, the symptom of "spinning" should be evaluated in the context of all other clinical features to correctly identify the presence of vertigo versus other types of dizziness.

Other important historical features are discussed in detail above. (See 'History' above.)

●Examination – In individuals with a history that suggests vertigo, physical examination should focus on oculomotor signs (especially the presence of nystagmus), hearing, balance, gait, tests of vestibular function, and the presence of focal neurologic findings to determine whether vestibular dysfunction is present and, if so, to localize the etiology to a peripheral or central vestibular abnormality (table 3). (See 'Physical examination' above.)

●Further evaluation of vertigo – In patients with vertigo, additional evaluation is dictated by the history and physical examination (algorithm 2).

Most children with vertigo will have otitis media, 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. (See 'Dizziness with vertigo' above and 'Vertigo' above.)

●Evaluation of other forms of dizziness – Patients with dizziness but no physical findings of vestibular dysfunction may describe a wide variety of symptoms but will lack signs and symptoms of vestibular dysfunction. The history, physical examination, and limited ancillary testing will often point to an underlying cause, especially in children with presyncope (table 1 and algorithm 3) or ataxia (algorithm 4). (See 'Dizziness without vertigo' above and 'Diagnostic approach' above.)

Potentially life-threatening causes of dizziness without vestibular dysfunction include cardiac arrhythmias, hypoglycemia, heat illness, 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".)

●Management – Successful management of dizziness consists of accurately diagnosing and treating the underlying cause as briefly described separately with links to detailed management discussions. (See "Causes of dizziness and vertigo in children and adolescents".)