Benign Paroxysmal Vertigo of Childhood

This entity was first described by Basser in 1964 (Basser LS. Benign paroxysmal vertigo of childhood. Brain 1964; 87:141-52), benign paroxysmal vertigo occurs in young children as episodes of unexplained fright/grotesque associated with disturbances in balance or even falls. The prevalence is 2-2.6% and the sex distribution is equal. Mostly the onset is sudden (95%) with an expression of anxiety and fear on the face of the child, who usually grasps any person standing nearby or any other object or else may sway or refuse to stand. The ataxia may remain unnoticed because some children refuse to leave their beds. Whereas the infants may cry but children with developed spoken language may complain of dizziness and nausea. A very attentive mother may also report nystagmus. The neuro-vegetative signs and symptoms like pallor, nausea, perspiration, photophobia, phonophobia, unusual head positions and vigorous vomiting are common. However, there is no loss of consciousness. In some children, the episode may evolve to syncope. The duration of episode is generally brief few seconds to < 5 minutes but sometimes lasts a few hours, with an utmost duration of 48 hours. The episode typically resolves with sleep but in few cases relief is obtained by lying or sitting down. The age of onset is between 2-4 years with range of 5 months to 8 years. The episode frequency varies from once every 1-3 months to once a day. Episodes tend to more frequent at first and become rarer with time and increasing age. The episodes may occur in clusters over several days and then subside for weeks or months. Triggers include roundabouts, swings, and seesaws, i.e., means of stimulating the labyrinth but may also include awakening, fever, tiredness, or stressful events. A positive family history of migraine, motion sickness and atopic disease is common. It is speculated that benign paroxysmal vertigo of childhood constitutes an early-onset variant of basilar-type migraine. It is suggested that benign paroxysmal vertigo of childhood consist of two entities - one would be a migraine equivalent with a family history of migraine and the other a more pure form without any relation to migraine. Benign paroxysmal vertigo is certainly under diagnosed because of the brief duration of attacks and their benign nature.Electroencephalogram tracings in waking and sleeping states, as well as during an episode, are normal. Audiologic examinations, including impedance measurement with stapedial reflex, always produce negative results. The vestibular examinations have failed to help explain the etiopathogenesis of the disorder considered by some authors  as a peripheral vestibular dysfunction, and by others as a central vestibular problem, with a deficiency of the vestibular nuclei or of the vestibular-cerebellar pathways. The differential diagnosis includes benign paroxysmal positional vertigo and episodic ataxia. Benign paroxysmal positional vertigo is the most common cause of vertigo in adults and is caused by a detachment of otoliths from the utricular macula and its inappropriate entry into semicircular canal but is rare in children. A diagnosis of episodic ataxia should prompt a trial of acetazolamide. The  tornado epilepsy, acoustic schwannoma and other tumors of the cerebellopontine angle, other posterior fossa tumours, Meniere’s disease and vestibular neuronitis are the other differentials that should be considered. Benign paroxysmal vertigo should also be differentiated from the idiopathic vertigo that may occur in association with migraine, because most children with migraine headache (typically older than in the age range when benign paroxysmal vertigo occurs) may report vertigo either just before or during a migraine headache. This is now a well defined entity called migraine associated dizziness. The benign paroxysmal vertigo of childhood disappears after a few months or a few years, usually by age 5 years (range, 2-16 years, i.e., after 3 months to 8 years) but evolution to migraine is frequent. In the short term, some children may develop a dysfunction classifiable as another childhood periodic syndrome, such as cyclic vomiting syndrome, or recurrent abdominal pain and motion sickness. In a single reported case, a woman manifested benign paroxysmal torticollis as a toddler, and then developed benign paroxysmal vertigo and finally migraine. Because attacks of benign paroxysmal vertigo are brief, no treatment is usually given. Treatment of an attack can include symptomatic medications such as antiemetics, although sleep will abort an attack in most patients. If attacks are frequent, one may consider prophylaxis with cyproheptadine.

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