Tinnitus, vertigo and balance disorders in children: Case

This girl has vestibular migraine. The cardinal features are recurrent episodes of vertigo lasting between twenty minutes and three hours over six months, the migraine features of nausea, photophobia, phonophobia, and a throbbing headache in at least half of the attacks, and a strong family history of migraine through her mother. She is a school-age adolescent, the age at which vestibular migraine is the commonest cause of recurrent vertigo, and her interictal examination, her pure-tone audiogram, and her tympanometry are all normal. The diagnosis rests on the consensus criteria of the Bárány Society and the International Headache Society, and her history meets them.

Excluding the dangerous causes

My first task is to exclude the central and the serious causes before I accept the benign diagnosis, and the normal interictal examination is the foundation of that exclusion. I confirm the absence of a focal neurological sign, an ataxia between attacks, a papilloedema, and a hearing loss, and I document that her eye movements show no gaze-evoked, direction-changing, or vertical nystagmus and that her head impulse test is normal. The pure-tone audiogram excludes an asymmetric or a progressive sensorineural hearing loss, which would raise a retrocochlear lesion and demand a gadolinium-enhanced magnetic resonance imaging. [7]

The red-flag screen is the safeguard that I apply to every dizzy child, and it is negative here. A new or a progressive headache, a focal sign, a papilloedema, a unilateral or a progressive hearing loss, or a direction-changing or a vertical nystagmus would each convert the diagnosis from a benign vestibular migraine to a central cause and would mandate urgent magnetic resonance imaging. The absence of these, together with the normal interictal examination and the normal audiogram, allows me to make the clinical diagnosis without routine imaging, and I would image only if a red flag appeared on the surveillance. [3]

Confirming the diagnosis

The diagnosis of vestibular migraine is made on the consensus criteria rather than on a single test, and this girl's history meets them. The criteria require recurrent vestibular symptoms lasting five minutes to seventy-two hours, a current or past history of migraine, or a family history, and one or more migraine features during at least half of the attacks, and the photophobia, the phonophobia, the nausea, and the headache during her attacks together with the maternal migraine satisfy them. I distinguish the condition from benign paroxysmal vertigo of childhood, which presents in a preschool child with attacks lasting seconds to minutes, and from benign paroxysmal positional vertigo, which gives brief position-triggered vertigo under a minute with a positive Dix-Hallpike. [1] [11]

The mechanism of vestibular migraine is an abnormal processing of vestibular and sensory information in a migraine-prone brain rather than a structural lesion, which explains why the vertigo occurs with or without headache and why the migraine features accompany the attacks. This mechanism also explains why the management shares its triggers and its prophylactic treatment with migraine headache, and I would explain this to the family as the basis of the plan. [11]

The management

My management begins with the lifestyle measures that address the migraine triggers, because the vertigo of vestibular migraine shares the triggers and the prognosis of migraine headache. I would counsel the girl and her family on regular sleep, adequate hydration, regular meals, the moderation of screen time, and the identification and the avoidance of her individual triggers, and I would explain that a substantial proportion of children improve on the lifestyle measures alone. I would address the school absence through a graduated return-to-learn plan and a clear communication with the school. [1]

I would add a migraine prophylaxis if the episodes remained frequent or disabling, because the two attacks a month and the school absence meet that threshold. The choice among propranolol, amitriptyline, and topiramate follows the paediatric migraine guidance and the individual comorbidity, and I would start one agent, titrate it, and judge the response over weeks to months. I would explain that the response is judged on the frequency, the severity, and the disability of the episodes and that the prophylaxis is shared with migraine headache, and I would review the girl regularly. [1] [11]

For the acute attack, I would use a short course of an antiemetic for the nausea alone and avoid the prolonged use of a vestibular suppressant, because its prolonged use delays the central compensation and is not the management of a recurrent episodic condition. The vestibular rehabilitation has a role if she develops a persistent imbalance between the attacks or a chronic vestibular hypofunction, and the rehabilitation drives the central compensation that restores the balance and the motor function. [10]

Prognosis, counselling, and follow-up

The prognosis of vestibular migraine is that of migraine across childhood, with a substantial proportion of children improving on the lifestyle measures and a minority requiring a prophylactic agent, and I would counsel the family accordingly. I would explain that the episodes may persist into adolescence and adulthood in a proportion but that the shared triggers and the prophylaxis give the family the tools to manage them, and I would address the psychosocial impact of a chronic episodic diagnosis on a teenager, including her mood, her sleep, and her school attendance. [1]

I would arrange the follow-up to monitor the response to the lifestyle measures and the prophylaxis, to titrate the agent, and to apply the red-flag screen at every visit. I would advise the family to return immediately if the pattern changed, if the episodes lengthened, if a headache became progressive, if a hearing loss appeared, or if a focal sign emerged, and I would image without delay if any of these appeared. The principle is that the benign diagnosis is made on the criteria, the dangerous causes are excluded through the red-flag screen, and the management is built on the lifestyle measures, the prophylaxis, and the safeguarding of the central signs. [3] [11]