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Vertigo

Amy Goldstein, M.D.

Amy Goldstein, MD is a Child Neurologist at the Children’s Hospital of Pittsburgh, where she is the Director of Neurogenetics and co-Director of the Neurofibromatosis Clinic. She is an Assistant Professor of Pediatrics at the University of Pittsburgh School of Medicine, where she attended medical school.  Dr. Goldstein has had a special interest in neurogenetic and neurometabolic disorders since her Pediatric intern year. She has been a member of the Board of Trustees of the United Mitochondrial Disease Foundation, and on the medical advisory board for MitoAction. She is the current President of the Mitochondrial Medicine Society and a member of the Society for Inherited Metabolic Disorders and the Child Neurology Society, where she helps plan the Neurogenetics Special Interest Group meetings. She has received several awards for patient satisfaction, including Best Doctors in Pittsburgh Magazine. She has contributed to recent literature on the diagnosis, management, and consensus criteria for mitochondrial disease. She was also involved in the completion of the Common Data Elements for Mitochondrial Disease through the National Institutes of Neurological Disorders and Stroke. She has reviewed articles for journals including Pediatric Neurology and Journal of Child Neurology.  Her current interests are in conducting clinical trials for patients with genetically confirmed mitochondrial disorders.

Overview

Vertigo is the sensation of movement which causes the reported symptom of dizziness or disequilibrium. Other symptoms may include:

  • nausea
  • vomiting
  • nystagmus (an abnormal eye movement)
  • sweating
  • weakness
  • difficulty walking
  • hearing problems

Young children may have trouble describing their symptoms, but will appear off-balance and the episodes tend to be of short duration. Preschool children might feel or look “clumsy”.

Vertigo is due to a problem in the inner ear (peripheral vertigo) or the brain (central vertigo). The frequent causes of vertigo in children include:

  • middle ear infection (otitis media)
  • inner ear infection (labyrinthitis/vestibular neuronitis)
  • benign paroxysmal vertigo (BPV)
  • migraine headache

The most common cause of vertigo in childhood is benign paroxysmal vertigo (BPV). BPV vertiginous episodes are sudden and may frighten the younger child. Symptoms include unsteadiness, loss of balance, paleness, nystagmus, but no loss of consciousness. Other rare causes of vertigo in children include head or neck injury (including concussion), stroke, brain tumor, multiple sclerosis, meningitis, and medications that can damage the ear.

Evaluation of vertigo should include taking the history of the illness from the child and caregiver, a physical examination, and laboratory testing (if indicated) to discover the underlying cause of the symptoms.

Treatment is supportive during the vertiginous episode, but chronic vertigo may require specific testing to investigate the cause and appropriate treatment with medications and/or physical (vestibular) therapy.

Description

Vertigo can be debilitating. The sensation of movement can cause difficulty walking, nausea and vomiting. The symptoms can last minutes to hours and may occur in recurrent episodes. Vertigo may affect 5% of children. Children with vertigo need to stop their activity;  more than half have a headache. Some also experience a change in hearing while having a vertiginous episode.

Symptoms can be limited to only the sensation of dizziness, but can range up to severe symptoms including nausea/vomiting, overall weakness, inability to walk, and difficulty moving the head (as it can induce symptoms). Some episodes last minutes to hours followed by long periods without symptoms; others may experience frequent episodes lasting days to weeks (chronic vertigo).

Children do not die from vertigo itself, unless the imbalance would lead to a life-threatening fall and injury. Rare causes of vertigo that could be life-threatening include tumor, head injury, and meningitis.

Symptoms

Vertigo is diagnosed based on the child’s symptoms and/or the caregiver’s observation. The physical exam may be normal or may demonstrate abnormalities such as nystagmus (an abnormal eye movement). Specific testing can be done to confirm vertigo and evaluate for the causes of vertigo; these include:

  • CT scan of the head
  • magnetic resonance imaging (MRI) brain scan
  • electrocardiogram (EKG)
  • electroencephalogram (EEG)

Vertigo is the sensation of dizziness, spinning, or movement (tilting, swaying, being pulled to one side) often triggered by head movement. Other symptoms that accompany vertigo may include nausea, vomiting, and an abnormal eye movement called nystagmus. Ringing in the ears (tinnitus) or hearing loss may be present. Symptoms can last a few minutes up to a few hours and attacks of vertigo may be recurrent.  Peripheral vertigo (due to problems with the vestibular nerve) is usually severe but short and includes nystagmus. Central vertigo (due to problems in the brain) is less severe, but longer lasting, and  is associated with other neurological symptoms.

Physical Abnormalities

Examination of the child with vertigo may be normal, especially if the child is not having symptoms at the time of exam. A maneuver called Dix-Hallpike can cause the symptoms (see Testing). During an episode, the child may be unable to walk, and may have nystagmus (abnormal eye movements), especially if the child has peripheral vertigo. A child with central vertigo may have other symptoms including weakness, abnormal sensory exam, increased deep tendon reflexes (hyperreflexia), and bulbar symptoms which include difficulty speaking (dysarthria) and difficulty swallowing (dysphagia).

Causation

Vertigo may be caused by normal phenomenon or from an underlying disease affecting the inner ear (labyrinth), Cranial Nerve VIII (vestibular/acoustic nerve), the brainstem, the cerebellum (brain’s balance center), the brain gray matter (cortex), and other causes such as a metabolic disturbance. Inner ear infection (labyrinthitis) is caused by a viral infection, but can also be from trauma or medication side effect/toxicity. Acute labyrinthitis can cause severe and sudden onset of vertigo with nystagmus, nausea, vomiting, and hearing loss. Cranial Nerve VIII (Vestibular/Acoustic nerve) can be inflamed or infected and is referred to as vestibular neuronitis. The brain can be affected by inflammation, infection, tumor, stroke, migraine, seizure, and multiple sclerosis. Other causes can include anemia, drug toxicity, vasculitis (auto-immune disorders causing vascular inflammation), or thyroid disease. Psychiatric causes include anxiety and hyperventilation.  The medications that may cause vertigo due to their ototoxicity (ear poisoning) side effects include the antibiotics streptomycin, minocycline, and aminoglycosides (gentamicin), and some chemotherapy. The ear damage that results from these medications can be permanent and lead to learning difficulties and chronic vertigo.

Infections include otitis media (middle ear infection) and meningitis. Bacterial meningitis is a serious infection which should be urgently evaluated and treated; meningitis may be accompanied by symptoms of vertigo, headache, neck stiffness, light sensitivity, vomiting, and confusion. Viral infections are often caused by mononucleosis (Epstein-Barr virus) and cause an acute vestibular neuropathy (vestibular neuritis/neuronitis). The difference between vestibular neuritis and labyrinthitis is that vestibular neuritis causes vertigo with intact hearing and labyrinthitis causes vertigo and hearing loss. Both are the result of ear infection and symptoms may last several weeks.

Migraine headaches can be accompanied by vertigo and migraine sufferers can have vertigo without the headache. Vertigo in children is considered a childhood migraine equivalent and is known as benign paroxysmal vertigo. Benign paroxysmal vertigo (BPV) is an episodic syndrome that may be associated with migraine. Vertigo attacks are sudden and severe, lasting minutes to hours, and resolve on their own. The vertigo in BPV may be associated with nystagmus, ataxia, nausea, and vomiting;  the child looks pale and fearful.

Ménière’s disease is a poorly understood condition that leads to abnormal fluid in the inner ear. Symptoms include:

  • vertigo/hearing loss
  • tinnitus
  • nausea
  • a sensation of fullness in the ear

Benign paroxysmal positional vertigo (BPPV), not to be confused with Benign paroxysmal vertigo (BPV), is a common cause of vertigo in adults but not in children. Vertigo occurs in paroxysms (episodes) and can be triggered by change in head position.

The most common causes in children (in descending order) are:

  1. migraine equivalent/benign paroxysmal vertigo of childhood (BPVC)
  2. head trauma
  3. ear disorders
  4. inner ear abnormality
  5. vestibular neuronitis
  6. labyrinthitis
  7. brain tumor

Head trauma can cause vertigo from the creation of a perilymphatic fistula, which is an abnormal connection between the inner ear and the middle ear; this has been well described in children. Children with head injury and concussion can develop prolonged symptoms (post-concussion syndrome) and vertigo is a common symptom.

Did anyone (did I) cause this? 

Some children are born with a hereditary tendency for vertigo; this situation is uncommon. Others might acquire it due to injury or infection.

Is the disorder hereditary? 

Family history of migraine should point to a diagnosis of benign paroxysmal vertigo of childhood (BPV or BPVC). About 20% of children who have BPV will go on to develop more typical headaches as they get older.

What are the causes?

  • Benign paroxysmal vertigo of childhood (BPV or BPVC): Not to be confused with benign paroxysmal positional vertigo (BPPV), BPV is the most common cause of vertigo in children and is thought to be a migraine equivalent. BPV is not associated with hearing loss or tinnitus. Children with BPV have their first episode by age 4 years, but can occur in older children up to age 12. The vertigo may last a few seconds and less than 1 minute. Children can become pale, sweaty, and vomit during the episode. There is no loss of consciousness or amnesia. The child is fine right afterwards and can go back to normal activity. The episodes might occur weekly or every few months and usually resolve completely after a few years. Examination is normal and testing can be normal. The family history reveals migraine headaches and the child may start to get typical migraines.
  • Labyrinthitis: An infection of the labyrinth of the inner ear. Vertigo is accompanied by hearing loss and tinnitus as well as nystagmus.
  • Vestibular neuritis: Attacks of vertigo are sudden, may last for days, and may be associated with hearing loss. Caused by inflammation of the vestibular nerve (Cranial Nerve VIII) due to an infection from herpes viruses, influenza, measles, rubella, mumps, polio, hepatitis, and Epstein-Barr virus (EBV). Vestibular neuritis is not seen in younger children less than 10 years old. Symptoms follow a viral infection (respiratory symptoms) and are severe vertigo, nystagmus, nausea and vomiting, but no hearing loss or tinnitus. Head movement worsens the vertigo and children prefer to lie down, usually with the affected ear up.
  • Ménière’disease: Attacks of vertigo are sudden and recurrent and associated with hearing loss and tinnitus (ringing in the ears) and a feeling of fullness in the affected ear. Symptoms can start suddenly, or after viral infection or head trauma. This is rare in children.
  • Acoustic neuroma: Vertigo is chronic and associated with unilateral (one-sided) hearing loss and tinnitus. Caused by a benign tumor on the acoustic nerve (Cranial Nerve VIII). Rare in children.
  • Stroke: Vertigo can be seen with a stroke caused by a loss of blood flow or clot in the brain. Other symptoms with vertigo include headache, eye deviation, and difficulty walking. Rare in children.
  • Multiple sclerosis: Vertigo may start suddenly and can be the initial symptom. Rare in children.
  • Head trauma/neck injury: Vertigo may start after injury and resolves on its own over time. May be seen in post-concussion syndrome. An injury may cause a temporal bone fracture (with damage to the labyrinth) causing vertigo, hearing loss, and blood behind the ear drum (hemotympanum). An injury to the side of the head may also cause a vestibular concussion, causing symptoms of vertigo, nausea, nystagmus, and other concussion symptoms (headache, confusion). Whiplash injury of the neck can cause vertigo. Trauma to the ear can also cause a perilymph fistula.
  • Migraine headache: Vertigo may accompany the headache, or can occur alone without headache in children who have a personal history or family history of migraine. May be treated with medication.
  • Anxiety/panic attacks: Vertigo is abrupt in onset, sometimes triggered by stress. Treated with psychotherapy or medication.
  • Benign paroxysmal positional vertigo (BPPV): Attacks of vertigo are sudden and brief, lasting a few seconds to a few minutes. Commonly triggered by moving the head, such as rolling over in bed. Can be treated with medication or vestibular therapy. BPPV is the most common cause of vertigo in adults; it is rare in children.

Can a child have more than one disorder? [e.g., autism and epilepsy]

A child may have vertigo and migraine, vertigo and seizures, vertigo and infection; based on the cause of vertigo there may be other diagnoses associated with the child’s condition.

Additional Concerns and Complications

Laboratory Investigations

When a child presents to a clinician for vertigo, the clinician should try to have the child explain the symptoms in the child’s own words. The caregiver can report observations of the episodes, with any associated symptoms (nausea, vomiting, nystagmus, hearing loss, feeling of ear fullness, tinnitus). Note when the symptoms start, how long they last, and how frequent the episodes occur, in addition to anything that might trigger the episode such as change in position, coughing or sneezing, or any other activities. The child’s past medical history, medications, family history should also be reviewed. A full physical exam should be performed, including ear exam and thorough eye exam.  If necessary, the child may then be referred for vestibular testing. If vertigo is present during or after a middle ear infection (otitis media), testing may also include:

  • bone films (to evaluate for mastoiditis)
  • CT of the head (to evaluate the ear structures)
  • lumbar puncture/spinal tap (to evaluate for meningitis)

Testing for vertigo may include “Vestibular Laboratory Testing” in order to assess the vestibular system and help identify the problem. Vestibular testing involves evaluation of the child’s walking (gait) and stance, eye exam to look for nystagmus, caloric testing (response of eye movement to water placed in the outer ear canal), positional testing, and electronystagmography (ENG).

Evaluation of gait (walking) and stance: If the child is having vertigo symptoms, they may walk veering off to one side or have significant balance problems.

Evaluation of nystagmus:  Nystagmus is an abnormal eye movement. The eyes appear to jerk or jiggle; it may occur with eyes straight ahead or when the child looks off in one direction. The child may need further evaluation by an ophthalmologist or neuro-ophthalmologist. Nystagmus sometimes needs to be evaluated by a specialist in a dark room while the child is wearing special goggles called Frenzel’s lenses.

Caloric testing: The child is lying down with the head elevated. Cold or warm water is introduced into an ear canal (after checking to make sure the ear drum in intact) in order to produce nystagmus as a normal response to this test. The eyes will get pulled in (cold water) or pushed away from (warm water) the direction of the ear that had water inserted, and the eyes will demonstrate nystagmus. If there is peripheral vertigo, the water may not produce a response from the eyes. “Directional preponderance” means that the cold water and warm water have the same effect and nystagmus is not seen.

 Positional testing: The Dix-Hallpike maneuver can induce nystagmus and symptoms of vertigo. The child starts by sitting up on an exam table, and then is quickly laid down with the head at an angle and brought below the level of the table. Nystagmus might appear 10-15 seconds after the position change and should last a short time if the cause is peripheral and benign. If the nystagmus begins immediately and lasts longer, the cause is located as central vertigo.

ENG (electronystagmography) testing: ENG testing is performed to measure eye movements which are recorded and analyzed either with small sticky-pad electrodes around the eyes (similar to an EKG) or with video recording (called videonystagmography or VNG).  The test can be done in a rotational chair to measure nystagmus. Younger children can be held in the lap of a caregiver. The four main parts of testing are calibration, tracking, position, and calorics.  ENG/VNG evaluates rapid eye movements while the child follows a moving object and eye movements while the head is placed in different positions. Caloric testing with cold and warm water can be performed as described above. Rotation tests measure the normal response of the eyes to move in the opposite direction of the head (called the vestibule-ocular reflex or VOR). The rotation chair will allow the measurement of eye movements at different speeds of head movement.

Therapeutic Intervention

Does treatment vary based on the severity?

Treatment of vertigo in children depends on the underlying cause, the duration, and frequency of the episodes.

What are the treatment options? 

Physical therapy, medications, and surgery are the usual treatments. In many cases, children can respond to a specialized form of physical therapy focused on balance, called Vestibular Therapy, or Vestibular Rehabilitation Therapy (VRT). VRT can be tailored to a child’s age and interests and can improve balance and reduce vertigo. Home exercises can be given to the caregiver by the vestibular therapist. VRT can be helpful for benign paroxysmal positional vertigo (BPPV), Ménière’s disease, labyrinthitis, vestibular neuritis and post-concussion vertigo when the symptoms persist for more than a few weeks.

Medical treatment of vertigo may include acute medications at the time of the attack:

  • Antihistamines (such as meclizine or promethazine) can be
  • Benzodiazepines (such as clonazepam or diazepam) may be used, but may be more sedating.
  • Scopolamine transdermal patch can also be effective.

Episodes that are brief, such as those in BPVC, should not require acute medication at the time of the episode. However, if the episodes are frequent, medications used for migraine prevention can be helpful for prevention of vertigo. These include propranolol, amitriptyline, topirimate and, for younger children, cyproheptadine.

Infectious causes of vertigo treatment may include antibiotics, drainage of the infection, and surgical excision of a cholesteatoma. The vertigo attacks may be longer in the case of vestibular neuronitis or labyrinthitis and require acute treatment. The medications used include:

  • meclizine hydrochloride
  • scopolamine transdermal patch
  • promethazine hydrochloride
  • metoclopramie
  • odansetron
  • diazepam
  • lorazepam
  • clonazepam
  • short course of corticosteroids
  • diphenhydramine
  • dimenhydrinate

What are the financial costs and are they covered by insurance?

The American Academy of Otolaryngology practice and advocacy guidelines has a position statement regarding Vestibular Rehabilitation:

“Vestibular Rehabilitation, or Balance Retraining Therapy, is a scientifically based and clinically valid therapeutic modality for the treatment of persistent dizziness and postural instability due to incomplete compensation after peripheral vestibular or central nervous system injury. Vestibular rehabilitation is a valid form of therapy for dizziness and imbalance resulting from the medical or surgical treatment of vertigo
disorders and for acute vertigo or persistent imbalance that may result from a variety of peripheral vestibular disorders. Balance Retraining Therapy is also of significant benefit for fall prevention in the elderly patient who may suffer from multiple sensory and motor impairments or for those who have sensory disruption with moving visual information.”

What are the side effects of each of the treatment options?

Some of the medications used in the acute treatment of vertigo can be sedating. The preventative medications each have their own side-effects as well. Before starting a prevention medication, the side-effects should be discussed with the child’s clinician.

What will happen if the disorder is not treated? 

Vertigo is usually self-limited, but if the episodes are frequent or long in duration, the child may benefit for vestibular therapy and/or medication.

What are the pros and cons of treatment?

The treatment and its associated side effects needs to be weighed against the disability and reduced quality of life the child experiences from having vertiginous episodes.

Prognosis

What is the prognosis with treatment? 

Overall prognosis depends on the cause of the vertigo. Some causes of vertigo will resolve shortly on their own, others need treatment with medication and/or vestibular therapy, and some causes may require other treatments (antibiotics, surgery) and become a chronic condition.

Labyrinthitis or vestibular neuritis creates an inflammation of the inner ear and may last days to weeks until the inflammation subsides.

Head or neck injury can cause vertigo of a long-lasting duration, but may respond to VRT and/or medication.

Peripheral vertigo (inner ear) will resolve on its own over time, but the vertigo can be very disruptive and therefore medication and VRT is prescribed with excellent results and resolution of vertigo.

Central vertigo (from a brain lesion such as tumor or stroke) can be long-lasting and may require emergency management by a neurosurgeon. Chronic vertigo may be difficult to resolve, even with medications and VRT.

What’s the likelihood that a child will be able to function in an independent capacity as an adult? 

Most children have peripheral vertigo and the prognosis is very good.

Is it possible to grow out of the disorder?

Most children will outgrow their vertigo, but this depends on the underlying cause.

How will this disorder affect daily life, activities, and development? 

Vertiginous episodes may be scary to the younger child and disruptive to the older child. Episodes may cause inability to walk, nausea, and vomiting.

How will the disorder affect the child’s ability to learn and grow?

Vertigo should not have a long-term impact on child’s ability to learn and grow unless it is due to an underlying central cause.

How will this disorder change the child’s life? 

The child may stop all activities during an acute episode. If there is a specific trigger for the vertiginous episodes, that activity may need to be avoided to prevent vertigo.

How will this disorder affect their school life and what does the school/teacher need to know to maximize their educational experience?

Children can receive physical and occupational therapy at school and teachers can implement vestibular exercises during school activities. Children may need an Individualized Education Plan or a Medical Disability Service Agreement for accommodations during the school day.

How will this disorder change the family? 

Episodes of vertigo can be very sudden and stop all activities for the child until the episode resolves. The episode may last seconds to minutes to hours;  the family will need to accommodate activities based on the child’s length of the vertiginous episode.

What will need to be done on a daily basis? 

Episodes of vertigo do not occur on a daily basis. However, if the child is in Vestibular Therapy or on medications, the treatment may need to be performed or given daily.

Can diet or exercise lessen the symptoms?

Diet may be modified in some cases if the child has a food trigger for the event, similar for migraine headache. Common food triggers include chocolate, monosodium glutamate, caffeine, and hard cheeses such as blue cheese. Exercises such as those taught in vestibular therapy can be very helpful.

Prevention

Vertigo can be prevented by avoiding triggers when possible. Falling is a common occurrence in children with vertigo and injury needs to be avoided.

Caretaker Augmentation

Are there organizations or support groups I can contact?

Vestibular Disorders Association ◦ www.vestibular.org, http://vestibular.org/finding-help-support/support-directory provides a comprehensive international list of support groups for vertigo

Are there organizations or support groups I can contact?

Vestibular Disorders Association ◦ www.vestibular.org, http://vestibular.org/finding-help-support/support-directory provides a comprehensive international list of support groups for vertigo

Further information can be found via the following links:

What resources are available for supplemental management and education?

If the child has frequent issues with vertigo or related symptoms, contact the child’s school to discuss accommodations, and Individualized Education plan, or a Medical Disability Service Agreement.

Glossary/Definitions

  • Benign paroxysmal vertigo: A childhood migraine equivalenBulbar symptoms: Refers to an area of the brainstem that controls the face and throat muscles; can be seen in central vertigo
  • Central vertigo: Vertigo due to a problem in the brain
  • Computed tomography (CT) scan: Radiation but quick study; best to view ear/bone structures
  • Cranial nerve VIII: the acoustic and vestibular nerve, responsible for hearing and balance
  • Dizziness: See Vertigo.
  • Dysarthria: A bulbar symptom, difficulty speaking
  • Dysphagia: A bulbar symptom, difficulty swallowing
  • Electrocardiogram (EKG): Measures electrical activity of the heart and looks for arrhythmias
  • Electroencephalogram (EEG): Measures electrical activity of the brain, looks for seizure tendency
  • Labyrinthitis: An infection of the labyrinth of the inner ear
  • Magnetic Resonance Imaging (MRI) scan: No radiation, but tends to be a longer study when looking at the brain; shows brain architecture better than CT
  • Meningitis: An infection of the meninges (the covering of the brain)
  • Migraine headache: Recurrent headache accompanied by light and noise sensitivity, nausea and, sometimes, vomiting
  • Nystagmus: An abnormal, jerking eye movement
  • Otitis media: An infection of the middle ear canal
  • Ototoxicity: Ear poison
  • Peripheral vertigo: Vertigo due to a problem with the vestibular nerve
  • Tinnitus: Perception of sound, ringing, or buzzing in the ears
  • Vertiginous episode: An episode of vertigo
  • Vertigo: The subjective sensation of movement, such as spinning, turning, tilting, or whirling, of the person or the surroundings
  • Vestibular nerve: Also known as the eighth cranial nerve (Cranial Nerve VIII); two branches include the vestibular nerve (for balance) and the acoustic nerve (for hearing)
  • Vestibular neuritis/neuronitis: Acute vestibular neuropathy, an infection of the vestibular nerve
  • Vestibular therapy: A specific type of physical therapy designed for people with vertigo 

References

Family Stories

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