REVIEW

CURRENT
OPINION Vertigo and dizziness in children
Klaus Jahn a,b, Thyra Langhagen a,c, and Florian Heinen a,c

Purpose of review
Vertigo and dizziness occur with considerable frequency in childhood and adolescence. Most causes are
benign and treatable. This review aims to make physicians more alert to the frequent causes of dizziness in
the young.
Recent findings
Epidemiological data confirm that migraine-related syndromes are the most common cause of vertigo in
children. Vestibular migraine and benign paroxysmal vertigo have now been defined by the International
Classification of Headache Disorders. About half of the adolescents with vertigo and dizziness show
psychiatric comorbidity and somatization. Vestibular paroxysmia has been described as a new entity in
children that can be treated with low doses of carbamazepine. To assess vestibular deficits, video head
impulses (for the semicircular canals) and vestibular-evoked myogenic potentials (for the otoliths) are
increasingly being used.
Summary
Pediatricians and neuro-otologists should be aware of the full spectrum of causes of vertigo and dizziness
in children and adolescents. Vestibular function can reliably be tested nowadays. Although treatment for
the common migraine-related syndromes can be done in analogy to the treatment of migraine in general,
specific approaches are required for somatoform vertigo, the most frequent diagnosis in adolescent girls.
Keywords
children, dizziness, migraine, motion sickness, paroxysmia, vertigo

INTRODUCTION EPIDEMIOLOGY AND DIAGNOSTIC

Vestibular deficits, vertigo, and dizziness in child-
hood may result in delayed postural control, lack of
coordination, and the development of paroxysmal
head tilt in young patients [1]. It is sometimes
difficult to make the correct diagnosis because chil-
dren are often unable to describe their vestibular
complaints [2]. They may also find it hard to say
how long attacks last and what provokes or accom-
panies them. A correct diagnosis, however, not only
obviates unnecessary investigations and alleviates
parental worries but also is the prerequisite for
successful therapy. Posterior fossa intracranial
tumors are often considered in the differential diag-
nosis, but such serious causes are fortunately rare.
Careful clinical examination of ocular-motor and
vestibular function allows a correct diagnosis. This
review focuses on three ‘hot’ topics discussed in the
recent literature: the diagnostic spectrum, labora-
tory tests, and migraine-related syndromes. In
addition, we will draw attention to vestibular
paroxysmia as a treatable cause of short spells
of vertigo.
SPECTRUM
Traditionally, it was assumed that vertigo and dizzi-
ness seldom occurred in childhood, despite the high
prevalence rates reported in epidemiological stud-
ies. Depending on the question asked and the age
group investigated, the 1-year prevalence for a single
attack of moderate-to-severe vertigo is between 5
and 25% [3]. The diagnostic spectrum of causes of
dizziness in children is known to differ from that in
adults. A recent meta-analysis of nine studies
a
German Center for Vertigo and Balance Disorders (DSGZ), bDepart-
Department of Neurology and cDepartment of Paediatric Neurology and
Developmental Medicine – Dr von Hauner Children’s Hospital, Klinikum
Grosshadern, Ludwig-Maximilians University, Munich, Germany
Correspondence to Prof Klaus Jahn, MD, German Center for Vertigo and
Balance Disorders (DSGZ) and Schön Klinik Bad Aibling, University
Hospital – Klinikum Grosshadern, Ludwig-Maximilians University, March-
ioninistrasse 15, Munich 81377, Germany. Tel: +49 89 4400 73671; fax:
+49 89 4400 76671; e-mail: klaus.jahn@med.uni-muenchen.de
Curr Opin Neurol 2015, 28:78–82
DOI:10.1097/WCO.0000000000000157

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 Vertigo and dizziness in children Jahn et al.

KEY POINTS

Migraine-related vertigo (vestibular migraine) is the OV
most common diagnosis in dizzy children. BPPV

Vestibular paroxysmia is an important differential Vestibular

VP migraine
diagnosis for frequent, short spells of vertigo.
25%

About half of dizzy children presenting to specialized
SV
units have psychiatric comorbidity.
7%

Serious causes of vertigo in childhood, for example, a
brain tumor, are rare.
CV

Vestibular testing can be reliably done with modern 8% BPV
techniques even in small children. 18%
HT
10%
PVS
(approximately, 800 subjects) on the prevalence and 13%
diagnosis of vestibular disorders in children
affirmed that benign paroxysmal vertigo (BPV) of
childhood (18.7%) and vestibular migraine (17.6%)
&& FIGURE 1. Diagnostic spectrum of the causes of dizziness in
are the most frequent diagnoses [4 ]. Both are
children. Data are pooled from Wiener-Vacher [7]
related to migraine. This proportion of about 40%
(n > 2000), Lehnen et al. [6 ] (n ¼ 400), and Gioacchini
&

of migraine-related syndromes in a population of

et al. [4 ] (n ¼ 724). Not all diagnoses were included in all
&&

dizzy children and adolescents fits well with the

studies. If a diagnosis was only recognized in one study and
experience of many tertiary referral centers [5]
did not overlap with the remaining groups (e.g., vestibular
(Table 1). The third most common cause of vertigo
paroxysmia first described in children by Lehnen et al. [6 ],
&

in children according to the meta-analysis was head

&& 4%), the group of unclear/other diagnoses (unlabeled, 11%)
trauma, with a rate of 14% [4 ]. Figure 1 summarizes
was reduced by an equivalent proportion to counterbalance
the diagnostic spectrum for more than 3000 chil-
the bias. BPPV and orthostatic vertigo each account for 2%
dren reported in the literature.
of the diagnoses. About 40% of patients are consistently
In addition to migraine, motion sickness is also a
diagnosed with migraine-related syndromes (vestibular
big issue in dizziness clinics for children. A popu-
migraine and BPV). BPPV, benign paroxysmal positioning
lation-based cross-sectional study of 831 children
vertigo; BPV, benign paroxysmal vertigo; CV, central vertigo
aged 7–12 years found that the prevalence of
(includes cerebellar syndromes, central ocular motor
motion sickness in this age group was more than
disorders, and episodic ataxia); HT, head trauma; OV,
40% when traveling by car or bus (but only 7% when
& orthostatic vertigo; PVS, peripheral vestibular syndrome
riding on a carousel [8 ]). There is still an ongoing
(includes unilateral and bilateral vestibular loss, vestibular
debate on what causes the high prevalence rate of
neuritis, labyrinthitis, Menière’s disease, and vertigo in
motion sickness in children. A sensory mismatch
middle ear effusion/otitis media); SV, somatoform vertigo
between vestibular–otolith and vestibular–canal
(includes phobic postural vertigo, chronic subjective
signals is likely to be more relevant than a vestibu-
dizziness, and vertigo in psychiatric disorders); VP,
lar–visual mismatch. The high susceptibility of sub-
vestibular paroxysmia.
jects between the ages of 5 and 10 may be because of
the different times of maturation of these systems
[9]. Most likely a combination of factors including life, they can be reliably tested even in toddlers [10].
exposure to stimuli and expectation contributes to Clinical tests can be accurately used to identify
&&
the phenomenon. Neurophysiological and psycho- children with vestibular hypofunction [11 ].
physical studies are needed to clarify the pathophy- Emerging new methods of vestibular testing in
siological concept in order to provide effective adults include the video head-impulse test (vHIT)
behavioral therapy. for quantifying vestibulo-ocular reflex (VOR) func-
tion [12,13] and the vestibular-evoked myogenic
potential (VEMP) for testing utricular and saccular
VESTIBULAR FUNCTION TESTS IN otolith functions [14,15 ].
&&

CHILDREN Although vHIT is now widely used to assess

Although the neuronal circuits for ocular motor and horizontal VOR function in adults [16,17], this
vestibular function develop within the first year of has not yet been validated for use in children.

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Neuro-ophthalmology and neuro-otology

Table 1. Differential diagnosis of vertigo and dizziness in children

Monophasic vertigo Episodic vertigo Persistent vertigo

Vestibular neuritis/ Vestibular migraine: attacks lasting minutes to Somatoform vertigo: subjective imbalance with
labyrinthitis: rotatory 72 hours, migraine headache, phonophobia/ normal findings on examination, aggravation in
vertigo, nausea, photophobia; Benign paroxysmal vertigo: attacks certain situations (in school, in department stores)
imbalance for days lasting seconds to minutes (to hours) without
migraine headache
Head trauma: vertigo/ Orthostatic vertigo: dizziness when getting up from Bilateral vestibular loss: gait instability in darkness
dizziness related to a supine or sitting position and on uneven ground, oscillopsia during walk-
the trauma ing
Vestibular paroxysmia: attacks lasting seconds to Central vertigo: pathological ocular-motor findings
minutes, with/without vestibulocochlear signs, such as gaze-evoked nystagmus, hypermetric
neurovascular cross-compression on MRI, saccades, skew deviation
response to low-dose carbamazepine
Benign paroxysmal positional vertigo: attacks
(lasting seconds to minutes) provoked by change
of head position relative to gravity; positional
nystagmus
Perilymph fistula: attacks (seconds) provoked by
coughing, sneezing, Valsalva

Instead, calorics and rotational chair testing are
applied. In contrast to head impulses, these tests
may induce unpleasant vertigo and nausea and are
consequently not always tolerated by children [1].
In addition, they are time-consuming and require
stationary equipment that is not available every-
where, especially at the bedside. In contrast, vHIT
can be done with the patient in a sitting position
and with the eyes open. Furthermore, the frequency
of the tested VOR function is in a physiological
range (>1 Hz compared with 0.003 Hz with calorics)
[18]. Preliminary evidence shows that vHIT can be
applied to children (>2 years) and is able to detect
even mild semicircular canal function deficits [19].
We are confident that it will replace caloric testing
in most situations in child neuro-otology in the
near future.
VEMP is a muscle reflex evoked by stimulating
the vestibular end organs (with sound, current, or
bone-conducted vibration). Two methods have
been described: the cervical (c) VEMP recorded from
the sternocleidomastoid muscles and the ocular (o)
VEMP recorded from extraocular muscles. In simple
terms, cVEMP is a test for saccular (inferior vestib-
ular nerve) and oVEMP is for utricular (superior
&
vestibular nerve) otolith functions [20 ]. In addition
to vHIT and calorics for semicircular canal testing,
VEMP has also been established in most vestibular
laboratories as a standard test. There is an increasing
number of reports on the use of VEMP testing in
&&
children [21 ] to demonstrate vestibular involve-
&&
ment in hearing impairments [22 ], identify young
patients with faulty cochlear implants [23–25], and
&&
detect impaired motor development [26 ] as well as
other specific deficits, such as congenital torticollis
[27]. An interesting recent study showed that unlike
calorics and cVEMP, oVEMP is not present in new-
borns, but it can be recorded in children older than 2
years of age who are able to walk without support
[9]. This finding has been discussed in the context of
balance control during locomotion, but it might
also be relevant for determining susceptibility to
motion sickness, which is usually absent in small
children under 2 years of age. Although VEMP is
increasingly used in children, it must be kept in
mind that findings have to be correlated with the
child’s complaints and clinical findings in order to
avoid overinterpreting the laboratory results.
MIGRAINE-RELATED VERTIGO
There is no doubt that migraine-related vertigo is
very common in children and adolescents [1]. More
than 50% of children who suffer from vertigo or
dizziness also have headaches [5,28]. The differen-
tiation of vestibular migraine and BPV is still a
matter of debate despite the fact that both are
defined in the new edition of the classification of
the International Headache Society (http://ihs-clas
sification.org/_downloads/mixed/International-Head
ache-Classification-III-ICHD-III-2013-Beta.pdf),
which was developed together with the Bárány
&&
Society [29 ,30].
BPV is one of the episodic syndromes that
may be associated with migraine and is often seen
& &&
as a precursor of migraine [31 ,32,33 ]. BPV is
characterized by recurrent brief attacks of vertigo
(seconds to minutes), occurring without warning

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and resolving spontaneously in otherwise healthy
&
children [34 ]. There is no age criterion; however,
BPV attacks are generally thought to begin occurring
in small children before their fourth birthday and to
disappear spontaneously at the age of 8–10 years
[35].
Vestibular migraine can affect all age groups.
The diagnosis requires a history of migraine with
or without aura. Vestibular symptoms can last 5
&
minutes to 72 hours [34 ]. Many epidemiological
series on dizziness in children have shown that
the separation of BPV and vestibular migraine is
arbitrary. Some authors see migraine equivalents
(such as BPV) as part of the migraine syndrome
[36]; others apply both diagnoses to the same
&
patient [37 ,38,39]. We would recommend using
the term BPV only for children who fulfill the diag-
nostic criteria but lack a personal history of migraine
headache. The other patients with episodic vertigo
that occurs together, at least, in part, with headache,
autonomic signs, and increased sensitivity to light
and sound should be diagnosed as having vestibular
&
migraine [34 ].
In our view, the literature largely neglects psy-
chiatric comorbidity and somatization when evalu-
ating the child with vertigo and dizziness. It is
known that almost half of adult patients with ver-
tigo/dizziness who present to a tertiary care unit
have had a psychiatric comorbidity [40]. About
40% of child migraineurs also fulfill criteria of soma-
toform vertigo when presenting at a specialized unit
(n ¼ 168). Somatoform vertigo in combination with
migraine is the most frequent diagnosis made in
adolescent girls [5]. A study from Korea showed a
similarly high prevalence of psychiatric comorbidity
in child patients with vertigo (n ¼ 105). The authors
reported that about half of the children had signifi-
cant levels of distress that might need psychiatric
&&
consultation [41 ]. As psychiatric comorbidities
adversely impact treatment outcomes, research on
the evaluation and treatment of this aspect is
urgently needed.
VESTIBULAR PAROXYSMIA: EASY TO
DIAGNOSE, EASY TO TREAT
Vestibular paroxysmia has been recently described
in children and should be considered in those who
& 1. Jahn K, Langhagen T, Schroeder AS, Heinen F. Vertigo and dizziness in
present with brief, frequent vertiginous spells [6 ]. It
is assumed that symptoms are caused by neurovas-
cular cross-compression of the eighth cranial nerve
at the root entry zone [42,43]. Positive diagnostic
criteria are frequent spells that last seconds to
minutes, occur at rest and with certain head posi-
tions, and respond to treatment with low-dose
sodium channel-blocking antiepileptics such as
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Vertigo and dizziness in children Jahn et al.
carbamazepine (2–4 mg/kg) [44]. This disabling dis-
order accounts for about 4% of all diagnoses in
vertiginous children presenting in the setting of
a tertiary referral center for vertigo and balance
disorders. This frequency is similar to that in adults
&
[6 ].
CONCLUSION
Pediatricians, neurologists, and otolaryngologists
who care for dizzy children and adolescents must
be aware of the differential diagnosis of episodic as
well as persistent syndromes. Although the progno-
sis of most episodic forms is benign (BPV, vestibular
migraine, and vestibular paroxysmia), the correct
diagnosis is a prerequisite for successful treatment.
Somatoform, sensory (e.g., bilateral peripheral ves-
tibular loss), and central vertigo can be distin-
guished by persistent complaints on the basis of
history taking and clinical examination. The diag-
nosis should also take the new diagnostic criteria
into consideration in order to ensure comparability
of diagnoses at different locations. There are effec-
tive therapies for most patients who present with
vertigo and dizziness. Studies on the pathophysiol-
ogy and treatment of somatoform vertigo in adoles-
cents are urgently needed to complete the picture of
this disorder.
Acknowledgements
The authors would like to thank Judy Benson for copy
editing the manuscript.
Financial support and sponsorship
This work was supported by the German Federal Ministry
of Education and Research (Grant BMBF IFB
01EO1401).
Conflicts of interest
There are no conflicts of interest.
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