Benign paroxysmal vertigo

When a child with a family history of migraine experiences vertigo, the diagnosis is often benign paroxysmal vertigo.  Unlike abdominal migraine and cyclic vomiting syndrome, this condition is exclusively seen in children. Adult migraineurs with symptoms of vertigo are diagnosed with other conditions, such as migraine with brainstem aura, Meniere’s disease, or migraine-associated vertigo (also referred to as vestibular migraine). The typical age of onset is around two years old. By age twelve, symptoms usually disappear. As with other associated symptoms, the presence of benign paroxysmal vertigo during the toddler years may be a precursor to migraine later in life. Many children will go on to develop migraine with brainstem aura (formerly basilar-type migraine).

Symptoms

Toddlers and preschoolers with this condition will often develop symptoms after walking and other gross motor skills have been successfully mastered. At this age children are not able to adequately describe their symptoms, so it’s important to know the behavioral signs. Toddlers are often clumsy. They lose their balance, bump into furniture and toys, misjudge distance and depth (due to a natural lack of depth perception), and fall frequently. These behaviors are considered a normal part of gross motor development. Benign paroxysmal vertigo, however, is something entirely different. Symptoms appear in repeated 5 minute attacks. The child’s eyes may move side to side, up and down, or around in circles involuntarily. Their movements may become jerky, causing them to drop objects, fall, or bump into things. Their skin becomes pale and clammy and they may vomit. Symptoms are strong enough to elicit a fearful response from the child. When the attack ends, the child will be able to resume active play with no recovery period. Between attacks, there are no symptoms to indicate a problem.

Diagnosis

As with other childhood disorders, a diagnosis of benign paroxysmal vertigo occurs when other conditions are ruled out.  The physician will check for ear infections, seizures, a head injury, tumors, or vestibular neuritis – any of which can mimic some of the symptoms of benign paroxysmal vertigo. A family history of migraine is often the first clue that benign paroxysmal vertigo is the problem. The doctor will then compare the child’s symptoms to the diagnostic criteria found in the ICHD-3.

Diagnostic criteria

  1. At least five attacks fulfilling criteria B and C.
  2. Vertigo occurring without warning, maximal at onset and resolving spontaneously after minutes to hours without loss of consciousness.
  3. At least one of the following associated symptoms or signs:

    A.  Nystagmus – a vision condition in which the eyes make repetitive, uncontrolled movements, often resulting in reduced vision. These involuntary eye movements can occur from side to side, up and down, or in a circular pattern.
    B.  Ataxia – a lack of muscle control during voluntary movements, such as walking or picking up objects.
    C.  Vomiting
    D.  Pallor – an unhealthy pale appearance.
    E. Fearfulness

  4. Normal neurological examination and audiometric and vestibular functions between attacks.
  5. Not attributed to another disorder.

Treatment

Due to the very young age of onset, there are few acute treatment options. The focus is generally on prevention, by encouraging parents to maintain a consistent, low stress schedule. Irregular meals and bedtime plus a stressful environment are typical triggers. The condition usually disappears within two years. A child with benign paroxysmal vertigo has a 24% chance of developing migraine later in life.

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