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]