You walk in to see your first patient of the day. The chief complaint on the chart says: “Concerned about seizures.” The patient is a 21/2-year-old, who has been your patient since his birth. You flip through the chart and see that he was last seen about 6 months ago for his 2-year checkup and at that time everything was fine. His development was appropriate; he was starting to put short phrases together, including “Go bye bye, NOW,” which he said so often that you made note of it in the chart. You wonder what could be going on.
You greet the mother, and say hi to Alex, who looks fine—and for the first time that you can remember, Alex is smiling at you. You ask mom what her concern is. She tells you that for the past few months Alex seems to suddenly lose his balance periodically. Initially mom thought little of it, figuring he was still working out the kinks in his walking skills, but she got concerned when she noted that Alex seemed to get very upset when this was happening. She also thought he looked a bit pale during each "episode," which lasts about 5 minutes. During one episode, she thought she saw Alex’s eyes “wiggling.” She mentioned these episodes to her mother, who reminded her that her cousin had convulsions. Now she’s worried.
Of course, findings from your examination of Alex are perfectly normal.
Your differential for a toddler-age child with episodes of what seems to be vertigo would include:
• Seizure disorder
• Otitis media
• Head trauma
• Vestibular neuritis
• Benign paroxysmal vertigo
• Less likely, but still things to think about, would be Meniere disease (rare in children), neurinomas, or positional vertigo.
Ingestions would also be considered, but the recurrent nature of the problem makes that much less likely.
You sit down with Alex’s mother and look further into the history. There is no history of trauma. You learn that the episodes tend to happen in clusters; they are absent for a while and then recur. Mom notes that they seem to occur more when Alex is overtired. Although he may be sleepy and may even sleep immediately after an episode, he is not postictal and has never lost consciousness and is completely back to normal after he sleeps. You are comfortable that there are no medications or solvents that Alex could be getting in to. The episodes do not seem to be related to viral illnesses, fevers, or ear tugging. You note that Alex had a few ear infections between 9 months and 21 months, but has not had any recently.
When the family history is reviewed, you find that the maternal grandmother had migraines. Mom denies migraines herself, but reports that she suffers from chronic sinus headaches that can be quite debilitating.
At this point you have ruled out otitis, ingestion, and head trauma. The intermittent recurrent nature of the problem makes vestibular neuritis unlikely. Because the family is concerned about epilepsy, you decide to order and EEG, knowing that a normal interictal EEG does not rule out seizure disorder. You hope results will reassure the family, even though you are pretty sure the patient has benign paroxysmal vertigo (BPV).
Benign Paroxysmal Vertigo
BPV is one of a group of disorders grouped together as “periodic syndromes of childhood” or “migraine precursors.”1 They include:
• Cyclic vomiting
• Abdominal migraine
• Benign paroxysmal torticollis
• Benign paroxysmal vertigo
The International Classification of Headache Disorders (2nd edition),2 or ICHD-II, describes BPV:
“1.3.3 Benign paroxysmal vertigo of childhood
A. At least 5 attacks fulfilling criterion B
B. Multiple episodes of severe vertigo* occurring without warning and resolving spontaneously after minutes to hours
C. Normal neurological examination; audiometric and vestibular functions between attacks
D. Normal electroencephalogram
*Often associated with nystagmus or vomiting; unilateral throbbing headache may occur in some attacks.”
BPV typically has an onset between 1 and 3 years, but has been reported in children as early as 5 months and as late as 8 years, with a prevalence of about 2.5%. Generally, a self-limited disorder, episodes tend to resolve in about 2 years. Episodes can be precipitated by the same factors as those in migraine: lack of sleep, stress, and diet.3 A family history of migraine is frequently elicited and there is an increased likelihood of developing migraine as the child grows (24% vs 10% in the general population).4 Specifically, there is an increased risk of basilar migraine as the child reaches school age.
Basilar migraine appears at a mean age of 7 years; headaches, which may be occipital, are preceded by an aura that lasts a few minutes to an hour. They are accompanied by dizziness, ataxia, vertigo, tinnitus, and/or visual disturbances.5,6
Back to Alex
What to do about your patient Alex? Medication is seldom necessary. Education is the key element of therapy. An explanation of the process and a discussion of possible triggers—lack of sleep, stress, missed meals, etc—is the most important intervention. The parents should also be told to be on the lookout for basilar migraine or migraine symptoms as the child grows up.
References:
1. Cuvellier JC, Lépine A. Childhood periodic syndromes. Pediatr Neurol. 2010;42:1-11.
2. Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd ed. Cephalalgia. 2004;24(suppl 1):9-160.
3. Ralli G, Atturo F, de Filippis C. Idiopathic benign paroxysmal vertigo in children, a migraine precursor. Int J Pediatr Otorhinolaryngol. 2009;73(suppl):S16-S18.
4. Drigo P, Carli G, Laverda AM. Benign paroxysmal vertigo of childhood. Brain Dev. 2001;23:38-41.
5. Al-Twaijri W, Shevell M. Pediatric migraine equivalents: occurrence and clinical features in practice. Pediatr Neurol. 2002;26:365-368.
6. Brenner M, Oakley C, Lewis D. Unusual headache syndromes in children. Curr Pain Headache Rep. 2007;11:383-389.
