Vertigo and Dizziness in Children: An Update

Research on sleep disorders in children with episodic idiopathic vertigo provides evidence supporting the connection to migraine

OBJECTIVES

Migraine is the most common etiology of episodic vertigo in pediatric populations. The characteristics of migraine headaches in children differ from those in adults, with initial manifestations frequently presenting as periodic syndromes. Sleep disorders are prevalent among individuals with migraines. Headaches may not be present in early childhood, and children may not easily report aura or phono-photophobia. Therefore, it is essential to identify clinical and anamnesic elements that can support the etiopathogenetic hypothesis of migraine in the assessment of episodic idiopathic vertigo. The objective of this study was to assess the validity of research concerning sleep disorders in children experiencing episodic vertigo, with the aim of providing evidence for a connection to migraine.

METHODS

The study included 25 participants diagnosed with episodic idiopathic vertigo, including 13 females and 12 males, aged between 5 and 14 years. A range of anamnestic parameters was analyzed, including the presence, type, and age of onset of sleep disorders; the presence, characteristics, and age of onset of headaches; and the presence of a family history of migraine. The data were compared with those of a control group matched for age and sex, which was affected by dysfunctional dysphonia and had no history of vertigo. The comparison of percentage values concerning the parameters under examination was conducted using the chi-square statistic test with Yates correction. A t-test was employed to compare the means and standard deviations. The significance limit is established for p values ≤ 0.05.

RESULTS

Sleep disorders were present in 15 out of 25 patients (60 %) with episodic vertigo, compared to 3 out of 25 (12 %) in the control group (p = 0.001). Somniloquy is the most prevalent disorder. Headache was reported by 12 out of 25 recruited patients (48 %), with 8 cases classified as migraine-type, 1 as tension-type, and 3 as mixed or indefinite-type. In the control group, 4 out of 25 (16 %) reported headaches, including 1 migraine-type, 2 tension-type, and 1 mixed or indefinite-type (p = 0.03). A family history of migraine was identified in 19 (76 %) of the 25 patients and in 7 (28 %) of the 25 subjects in the control group (p = 0.001). The average age of onset for sleep disorders was 6.28 ± 1.67 years, while for headaches it was 9.25 ± 3.01 years (p = 0.01). The comparative analysis of symptom distribution by patient age indicates that all patients with sleep disorders reported this clinical manifestation by the age of eight years. Conversely, only 26.6 % of these patients reported experiencing the headache for the first time at the same age.

CONCLUSIONS

Children with episodic idiopathic vertigo exhibit a high prevalence of sleep disorders, alongside a significant correlation with headaches and a familial history of migraine. In younger patients, migraine symptoms, particularly headache, necessary for diagnosing vestibular migraine, are frequently absent or unreported. Studies on sleep disorders in children experiencing episodic idiopathic vertigo indicate a correlation with migraine.

Recurrent dizziness among adolescents in Denmark: Trends 1991-2022 and associations with sociodemographic factors, health, and health behaviours

1) to study time trends in the prevalence of recurrent dizziness among adolescents in Denmark 1991-2022, and 2) to examine how dizziness was associated with sociodemographic factors, mental health related factors, health status, and health behaviours in 2022. The study focused on recurrent dizziness, i.e. episodes of dizziness several times a week during the last six months. Data stem from the Danish arm of the international Health Behaviour in School-aged Children (HBSC) study which included 11-, 13- and 15-year-olds from random samples of schools in nine comparable surveys from 1991 to 2022, n = 40,102. We applied multivariate logistic regression analyses in the 2022 dataset (n = 5,737) to examine how dizziness was associated with other factors. In 2022, the prevalence of recurrent dizziness was 14.3% (boys 8.8%, girls 19.7%), significantly higher than the 7.1% in the surveys 1991-2018. The prevalence in 2022 was significantly higher among girls, older students, and students not living with both parents. Dizziness was significantly elevated among students with short sleep duration, who skipped breakfast, used alcohol and tobacco, felt lonely, had low life satisfaction, low self-esteem, were exposed to bullying at school, felt high schoolwork pressure, low school satisfaction, who were underweight, overweight, had poor self-rated health, chronic illness, injuries in the last year, headache, stomachache, backpain, feeling low, irritability/bad temper, nervousness, difficulties falling asleep, and poor/restless sleep.

CONCLUSION

The study suggested that dizziness is a general indicator of not feeling well, run down, or suffering rather than a sign of specific somatic health problems.

WHAT IS KNOWN

• Recurrent dizziness is common among adolescents and may limit daily activities and harm quality of life. • Recurrent dizziness in adolescence may reflect somatic and mental health problems and is strongly associated with headache.

WHAT IS NEW

• The prevalence of recurrent dizziness among adolescents in Denmark was stable 1991-2018 and increased steeply from 2018 to 2022. • Recurrent dizziness was strongly associated with poor health behaviours, a broad range of somatic and mental health problems, and exposure to stressors.

Audiovestibular adverse events following COVID-19 vaccinations

INTRODUCTION

Evidence regarding audiovestibular adverse events post COVID-19 vaccination to date has been inconclusive regarding a potential association. This study aimed to determine if there was an increase in audiovestibular events following COVID-19 vaccination in South-eastern Australia during January 2021-March 2023.

METHODS

A multi-data source approach was applied. First, a retrospective observational analysis of spontaneous reports of audiovestibular events to a statewide vaccine safety surveillance service, SAEFVIC. Second, a self-controlled case series analysis using general practice data collected via the POpulation Level Analysis and Reporting (POLAR) tool.

RESULTS AND CONCLUSIONS

This study is the first to demonstrate an increase in general practice presentations of vertigo following mRNA vaccines (RI = 1.40, P <.001), and tinnitus following both the Vaxzevria® adenovirus vector and mRNA vaccines (RI = 2.25, P <.001 and 1.53, P <.001 respectively). There was no increase in hearing loss following any COVID-19 vaccinations. Our study, however, was unable to account for the potential of concurrent COVID-19 infections, which literature has indicated to be associated with audiovestibular events. Healthcare providers and vaccinees should be alert to potential audiovestibular complaints after COVID-19 vaccination. Our analysis highlights the importance of using large real-world datasets to gather reliable evidence for public health decision making.

Instrumental Assessment and Pharmacological Treatment of Migraine-Related Vertigo in Pediatric Age

BACKGROUND

The most frequent form of vertigo in pediatric age is represented by vertigo linked to migraine, with a prevalence of 32.7%. This group of pathologies has received a redefinition of the diagnostic criteria to adapt them to the pediatric age with a new classification of the clinical pictures. We have several kinds of problems with these conditions that often have a significant impact on patients' and parents' quality of life: the diagnostic approach involves different tools for the different age groups contained in the pediatric range; the treatment of this type of vertigo is not consolidated due to the limited availability of trials carried out on pediatric patients. Focusing on this topic, the aim of this review was to provide an update on the more recent clinical advances in the diagnosis and treatment of Vestibular Migraine (VM) in children.

METHODS

We searched the PubMed, Embase, and Cochrane library databases for articles published in English from January 2015 to April 2023. The secondary search included articles from reference lists, identified by the primary search. Records were first screened by title/abstract, and then full-text articles were retrieved for eligibility evaluation. The searches combined a range of key terms ("Pediatric" AND "Childhood" AND "dizziness" OR "vertigo" AND "vestibular").

RESULTS

Migraine-related vertigo, in its most recent definitions and classifications, is the most frequent group of balance pathologies in pediatric age. The results from the various experiences present in the literature suggest a clinical approach to be integrated with the use of instrumental tests selected according to the age of the patient and the reliability of the results.

CONCLUSION

Knowing the timeline of the applicability of vestibular tests and the information that can be obtained from them is fundamental for diagnostic accuracy. Therapy is strongly conditioned by the limited availability of pediatric trials and by the wide range it includes, from very young children to adolescents.

Visual vertigo in children: Adaptation and validation of the visual vertigo analogue scale to European Portuguese

BACKGROUND

Visual vertigo occurs after vestibular and non-vestibular pathology and can be present in children and adolescents. It can be assessed by "the Visual Vertigo Analogue Scale" (VVAS), a questionnaire with a Portuguese version for adults.

OBJECTIVES

To perform the adaptation to pediatric age and validation of VVAS in European Portuguese.

METHODS

This prospective study involved the pediatric adaptation of the Portuguese VVAS, according to recognized guidelines. It was then completed by 30 healthy controls and 18 children with vestibulopathy. Patient caregivers also completed the Dizziness Handicap Inventory - Patient Caregivers (DHI-PC) to further explore the link between questionnaires. Groups were compared for severity of visual vertigo and VVAS test-retest reliability was tested.

RESULTS

The VVAS score was significantly higher in vestibular group (p < 0.001). No statistically significant differences were found between VVAS initial and re-test scores (p = 0.33). VVAS severity scores showed a positive correlation with DHI-PC (r = 0.598, p = 0.009).

CONCLUSION

The present Pediatric adaptation of VVAS in European Portuguese shows good psychometric properties for the assessment of visual vertigo. A positive correlation with the DHI-PC was showed, establishing the potential use of both questionnaires in the evaluation of vertigo children.

Validity of Italian adaptation of the Vanderbilt Paediatric Dizziness Handicap Inventory

Objective

The paediatric caregiver version of the Dizziness Handicap Inventory (DHI-PC) questionnaire is a useful Quality of Life (QoL) evaluation instrument for children experiencing dizziness, vertigo or unsteadiness. Its English version has been validated for use with a paediatric population between 5 and 12 years of age. The aim of this work is to validate the DHI-PC into Italian for both patient assessment and appropriate rehabilitative treatment planning.

Materials and methods

Cross-cultural adaptation of the DHI-PC was performed using standard techniques. Items of the original questionnaire were translated into Italian by two bilingual investigators. Two native English speakers carried out a back translation of the new version that was compared with the original to check that they had the same semantic value. A pre-final version was obtained by an expert committee and was applied in a pilot test.

Results

A total of 42 patient caregivers completed the final adapted questionnaire twice with an interval of 2 weeks. Internal consistency was excellent, with Cronbach's alpha = 0.95.

Conclusions

Our study showed evidence that the Italian version of DHI-PC is a valid and reliable tool to quantify the degree of dizziness handicap and its application is recommended.

Vertigo and dizziness in children: When to consider a neurological cause

Vertigo is common in childhood and adolescence. Although children and adults share common causes of vertigo, epidemiology changes with aging. For instance, ischemic stroke is less frequent in childhood, whereas audiovestibular disorders, such as vestibular neuritis and the migraine equivalent, are the leading causes of vertigo. However, even if severe causes of vertigo are rare, clinicians must not miss them. In this review, we discuss the neurological causes of central vertigo in children. The diagnostic approaches reviewed here are focused on the search for signs of severity, such as an abrupt onset, infectious context, or intracranial hypertension, which may subsequently require brain imaging.

Normative values for the video Head Impulse Test in children without otoneurologic symptoms and their evolution across childhood by gender

PURPOSE

The video Head Impulse Test is routinely used to assess semicircular canal function in adults, but to date, pediatric reference values are scarce. This study aimed to explore the vestibulo-ocular reflex (VOR) in healthy children at different development stages and to compare the obtained gain values with reference to those in an adult population.

METHODS

This prospective, single-center study recruited 187 children from among patients without otoneurological diseases, healthy relatives of these patients, and staff families from a tertiary hospital. Patients were divided into three groups by age: 3-6 years, 7-10 years, and 11-16 years. The vestibulo-ocular reflex was assessed by video Head Impulse Test, using a device with a high-speed infrared camera and accelerometer (EyeSeeCam®; Interacoustics, Denmark).

RESULTS

We found a lower vestibulo-ocular reflex gain of both horizontal canals in the 3-6-year-old group when compared with the other age groups. No increasing trend was found in the horizontal canals from age 7-10 years to age 11-16 years, and no differences were found by sex.

CONCLUSION

Gain values in the horizontal canals increased with age until children reached age 7-10 years and matched the normal values for adults.

Phenotypes, bedside examination, and video head impulse test in vestibular migraine of childhood compared with probable vestibular migraine and recurrent vertigo in childhood

Introduction

Vestibular impairment and vertigo in the pediatric population have an estimated prevalence ranging between 0.4% and 5.6% and are a topic of interest in recent years. The Bárány Society has recently reclassified migraine-related vertigo syndromes as vestibular migraine of childhood (VMC), probable vestibular migraine of childhood (probable VMC), and recurrent vertigo of childhood (RVC).

Methods

Applying the criteria established by the Bárány Society, we retrospectively analyzed data on 95 pediatric patients suffering from episodic vertigo that were recruited from 2018 to 2022. In applying the revised criteria, 28 patients had VMC, 38 had probable VMC, and 29 had RVC.

Results

Visuo-vestibular symptoms (external vertigo) or internal vertigo were reported by 20 of 28 VMC patients (71.4%) compared to 8 of 38 probable VMC patients (21%) (P < .001). None of the RVC patients reported external vertigo. Duration of vertigo was demonstrably longer in the VMC patients than in the probable VMC (P < .001) and RVC (P < .001) patients. Cochlear symptoms were reported by 28.6% of VMC patients and by 13.1% of probable VMC patients. No cochlear symptoms were reported by any RVC patients. Familial cases for headache and episodic vertigo showed no significant difference between groups.

Discussion

The most frequent finding during bedside examination in all three groups was central positional nystagmus. Differences in the duration of attacks and in accompanying symptoms may underline different pathophysiological mechanisms.

Rare Coding Variants in Patients with Non-Syndromic Vestibular Dysfunction

Vertigo due to vestibular dysfunction is rare in children. The elucidation of its etiology will improve clinical management and the quality of life of patients. Genes for vestibular dysfunction were previously identified in patients with both hearing loss and vertigo. This study aimed to identify rare, coding variants in children with peripheral vertigo but no hearing loss, and in patients with potentially overlapping phenotypes, namely, Meniere's disease or idiopathic scoliosis. Rare variants were selected from the exome sequence data of 5 American children with vertigo, 226 Spanish patients with Meniere's disease, and 38 European-American probands with scoliosis. In children with vertigo, 17 variants were found in 15 genes involved in migraine, musculoskeletal phenotypes, and vestibular development. Three genes, OTOP1, HMX3, and LAMA2, have knockout mouse models for vestibular dysfunction. Moreover, HMX3 and LAMA2 were expressed in human vestibular tissues. Rare variants within ECM1, OTOP1, and OTOP2 were each identified in three adult patients with Meniere's disease. Additionally, an OTOP1 variant was identified in 11 adolescents with lateral semicircular canal asymmetry, 10 of whom have scoliosis. We hypothesize that peripheral vestibular dysfunction in children may be due to multiple rare variants within genes that are involved in the inner ear structure, migraine, and musculoskeletal disease.

The global prevalence of vestibular dysfunction in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Vestibular dysfunction has been extensively studied amongst the older population. Recently, conditions and management of vestibular dysfunction among children and adolescent has gained attention. Yet, a lack of awareness and expertise in managing children and adolescents with vestibular dysfunction has led to a delay in diagnosis as well as a trifling prevalence rate.

AIM

To conduct a systematic review and meta-analyses to estimate the overall pooled prevalence of vestibular dysfunction in children and adolescents.

METHODS

PubMed, Scopus, and Web of Science databases were searched to identify studies published until 29 April 2022. We used a random-effects model to estimate the pooled prevalence with 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic and Cochran's Q test. The robustness of the pooled estimates was checked by different subgroups and sensitivity analyses.

RESULTS

We identified 1811 studies, of which 39 studies (n = 323,663) were included in the meta-analysis. Overall, the pooled prevalence of children and adolescents with VD was 30.4% [95% CI 28.5-32.3%]. The age of the participants ranged from 1 to 19 years. Participants of the included 39 studies were from 15 countries. Among the studies, 34 were cross-sectional, and five were case-control designed. There were discrepancies found in the studies with objective (higher prevalence) versus subjective (lower prevalence) evaluations.

CONCLUSION

The prevalence of VD among children and adolescents was found to be 30.4% based on high-quality evidence. Due to the subjective assessment of most studies pooled in the analysis, the results should be interpreted cautiously until future comparative studies with objective assessments are carried out.

Characteristics of vestibular migraine, probable vestibular migraine, and recurrent vertigo of childhood in caloric and video head impulse tests

OBJECTIVE

Vertigo is very common in children, but the specific diagnosis and characteristics are not clear. The main objective of this study was to analyze the characteristics of caloric test (CT) and video head impulse test (vHIT) in vestibular migraine of childhood (VMC), probable vestibular migraine of childhood (PVMC), and recurrent vertigo of childhood (RVC), which can provide a reference value for their clinical diagnosis.

METHODS

We selected VMC, PVMC and RVC patients under 18 years of age from the outpatient Department of Otolaryngology-Head and Neck Surgery between May 2021 and August 2022. All patients underwent vestibular function examinations, including eye movement recording CT and vHIT. CT results depended on whether both canal paresis and directional preponderance were under normal limits, and vHIT results depended on the gain values of vestibulo-ocular reflex. The results of both tests were analyzed according to the disease type.

RESULTS

Among the 81 pediatric vertigo patients aged 5-17 years, 44 were females and 37 were males. According to the type of vertigo, 29 patients (25.80%) were diagnosed with VMC, 11 (13.58%) with PVMC, and 41 (50.62%) with RVC. The abnormal rates of the CT in VMC, PVMC, and RVC patients were 24.14%, 36.36%, and 17.07%, respectively. There was no significant difference in the abnormal rates among the three groups (P > 0.05). None of the patients showed abnormal vHIT results (all abnormal rates 0.00%). The abnormal CT rates were significantly higher than those of abnormal vHIT rates (P < 0.05).

CONCLUSIONS

VMC, PVMC, and RVC are more likely to be diagnosed by symptoms, as neither CT nor vHIT are specific to any conditions. Due to different clinical presentations of vertigo in pediatric patients, it is critical to further clarify the diagnosis with medical history and clinical characteristics.

Balance Disorders in Children and Adolescents

The prevalence of balance disorders in children and adolescents is extremely variable [...]

The Narrowed Internal Auditory Canal: A Distinct Etiology of Pediatric Vestibular Paroxysmia

Vestibular paroxysmia (VP) is a disorder encountered in the pediatric population that etiology has been attributed to neurovascular cross-compression syndrome (NVCC). The purpose of this study was to report a new probable pathological condition, the narrowed internal auditory canal (IAC), which appears to be involved in the development of a clinical picture of VP in the pediatric population. A retrospective descriptive comparative study was conducted to compare clinical, electrophysiological, radiological, and therapeutic outcomes in both etiologies. Overall, 16 pediatric patients suffering from VP were included and divided into two groups: patients with narrowed internal auditory (Group 1) were compared to those with NVCC syndrome (Group 2). Patients in both groups were similar in terms of auditory complaints, as well as hearing, vestibular, and electrophysiological status. A narrowed IAC was encountered in the adolescent age category and females, especially those with rapid growth. The diagnosis requires a careful analysis of the shape and diameters of the IAC. Radiologic measurements in the axial plane do not seem to be sufficient to confirm the diagnosis, and, therefore, an analysis of diameters in the coronal plane is required. Treatment with sodium-channel blockers drugs showed promising results not only by relieving vertigo but also by normalizing the electrophysiological findings. In conclusion, a narrowed IAC can be considered in patients suffering from VP.

The Pharmacological Treatment of Pediatric Vertigo

Vertigo in children is a challenging topic. The lack of dedicated trials, guidelines and papers causes inhomogeneity in the treatment of vertigo in children. Meniere’s disease, migraine equivalents, vestibular neuritis, paroxysmal positional benign vertigo (BPPV), persistent postural-perceptual dizziness (PPPD) and motion sickness may affect children with various degrees of incidence and clinical severity compared to adults. Several drugs are proposed for the management of these conditions, even if their use is subordinated to the child’s age. In this review, we summarize the existing evidence related to the use of drugs for this clinical condition in children as a start point for new trials, stating the urgent need for international guidelines.