Benign Paroxysmal Vertigo: The Essentials

Benign Paroxysmal Vertigo is a rare Migraine variant occurring in young children with a family history of Migraine. It should not be confused with benign paroxysmal positional vertigo, a vestibular disorder that’s more often seen in adults over age 50. Symptoms typically first appear when a child is two years old and disappear by age 12. Children with Benign Paroxysmal Vertigo may develop Migraine with brainstem aura later in life.

Symptoms

Toddlers are naturally 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 after the child has mastered walking.
• Children are unable to describe their symptoms, so behavior clues inform a diagnosis.
• Symptoms appear in repeated five minute attacks.
• The child’s eyes may involuntarily move side-to-side, up and down, or around in circles.
• Movements become jerky, causing the child to drop objects, fall, or bump into things
• Skin becomes pale and clammy.
• Vomiting may occur.
• The child responds fearfully to these symptoms
• Once the attack ends, the child resumes normal activities without rest or recovery.

Getting a diagnosis

As with other childhood disorders, a diagnosis of Benign Paroxysmal Vertigo is given 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.

ICHD-3 Diagnostic Criteria:

Description:

A disorder characterized by recurrent brief attacks of vertigo, occurring without warning and resolving spontaneously, in otherwise healthy children.

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:
   • 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.
   • Ataxia – a lack of muscle control during voluntary movements, such as walking or picking up objects.
   • Vomiting
   • Pallor – an unhealthy pale appearance.
   • Fearfulness
4. Normal neurological examination and audiometric and vestibular functions between attacks.
5. Not attributed to another disorder.

Notes:

1. Young children with vertigo may not be able to describe vertiginous symptoms. Parental observation of episodic periods of unsteadiness may be interpreted as vertigo in young children.
2. In particular, posterior fossa tumours, seizures and vestibular disorders have been excluded.

Comment:

The relationship between 1.6.2 Benign paroxysmal vertigo and A1.6.6 Vestibular migraine (see Appendix) needs to be further examined.

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.

Sources:

1. Batson G. Benign paroxysmal vertigo of childhood: A review of the literature. Paediatrics & Child Health. 2004;9(1):31-34.
2. International Headache Society (IHS) (2018). 1.6.2 Benign paroxysmal vertigo. (n.d.). Retrieved April 23, 2018, from https://www.ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-2-paroxysmal-hemicrania/
3. Migraine Variants In Children. American Migraine Foundation, Retrieved online 23 April 2018 at https://americanmigrainefoundation.org/understanding-migraine/migraine-variants-in-children/.