Dizziness and Orthostatic Intolerance In Pediatric Headache Patients

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Children and adolescents with headaches commonly complain of dizziness that creates significant distress among the patients and their families. Dizziness is largely due to either orthostatic intolerance or vertigo; this distinction is the initial step in the evaluation of a child with co-occurrence of headaches and dizziness. Vertiginous symptoms are most commonly due to vestibular migraine or benign positional vertigo. This review would focus its attention on the diagnosis, evaluation, and management of orthostatic intolerance, specifically postural orthostatic tachycardia syndrome.

Introduction

Dizziness occurs in 5%-8% of children and up to 60% of children report concurrent headache with their dizziness.1, 2 Adults with migraine have a 51.7% lifetime prevalence of vertigo or dizziness compared with 31.5% in a healthy control population.3 These symptoms can cause significant distress to the children and their parents. For a primary care provider and pediatric neurologist, accurate diagnosis leads to appropriate treatment and subsequent improvement in quality of life.

The first step of evaluation is determining the nature of the dizziness—is the child having the sensation of lightheadedness or vertigo? Lightheadedness is described as feeling faint, as if the blood is rushing out of one׳s head, and in extreme cases may result in syncope. Lightheadedness is commonly due to orthostatic dysfunction. Vertigo is the sensation of movement, feeling off-balance, spinning, or tilting. This sensation could be present for the children themselves or the surroundings. Vertigo is a common sign of vestibular dysfunction. In children, it is important to determine if vertigo is from a balance issue due to ataxia or cerebellar dysfunction.

Herein, we would focus on orthostatic intolerance (OI) and syncope, in addition to providing a review of migraine syndromes that have dizziness or vertigo as a predominant feature (Table 1). We would review postural orthostatic tachycardia syndrome (POTS), a common comorbidity of the migraineur as well as therapeutic strategies for managing OI.

Section snippets

OI and Basic Physiology of Orthostasis

Orthostasis is maintenance of upright, standing posture. Orthostatic hypotension is defined as a systolic blood pressure decrease of ≥20 mm Hg or diastolic blood pressure decline of ≥10 mm Hg within 3 minutes of standing or with tilt-table testing to 60°.4 Migraineurs have been shown to be at increased risk of OI, a transient range of symptoms including lightheadedness, headache, fatigue, abdominal pain, and syncope, which arise from upright posture.5 OI in turn may exacerbate migraine symptoms.

Neurally Mediated Hypotension

Neurally mediated hypotension (NMH) is the most common cause of syncope. It is also referred to as neurally mediated syncope, vasovagal syncope, vasodepressor syncope, reflex syncope, and neurocardiogenic syncope. Syncope is a transient loss of consciousness and tone resulting from holocephalic hypoperfusion followed by spontaneous, full recovery NMH. This typically occurs while in standing position (postural NMH) and is associated with reductions in HR or blood pressure or both. It is defined

Definition

POTS is a heterogenous syndrome involving systemic symptoms resulting from autonomic dysregulation with orthostasis. The most common symptoms in patients with POTS include dizziness (84%-95%), weakness (72%-94%), and orthostatic syncope (62.7%); other common symptoms are palpitations, nausea, fatigue, exercise intolerance, headaches, poor sleep quality with daytime sleepiness, abdominal pain, and edema.6, 7, 8 A study of 37 adolescents with POTS found all patients to have tension headache or

Chronic Subjective Dizziness

The term chronic subjective dizziness (CSD) was introduced in the literature by Staab et al45 Preceding terminology includes phobic postural vertigo, psychogenic dizziness, or chronic dizziness. It is the second most common diagnosis just after benign paroxysmal positional vertigo and ahead of vestibular migraine (VM) identified in tertiary centers by neuro-otology specialists.46 Its prevalence in the pediatric population is unknown. CSD has also been identified as a common comorbidity in VM

Vertigo and Headaches

Vertigo in children is most commonly due to VM or benign paroxysmal vertigo. Other causes can include migraine with brainstem aura and secondary causes of vertigo such as central nervous system lesions or posterior fossa tumors.

Vestibular Migraine

In children and adolescents with migraine, it is important to differentiate OI syndromes from VM that has been previously called migraine-associated vertigo or dizziness, migraine-related vestibulopathy, or migrainous vertigo. In a retrospective study of children presenting with vertigo, 11 of 100 children were eventually diagnosed with migraine-associated vertigo.52 Another study of pediatric patients with vertigo found that 73% reported a history of headache, with 54% occurring simultaneously

Migraine With Brainstem Aura

Migraine with brainstem aura consists of brainstem symptoms without motor weakness, including vertigo that occurs with or precedes a headache by up to 60 minutes. It has been previously referred to as basilar artery migraine and basilar migraine. Prevalence in children is unknown, but in a study of 111 children diagnosed with migraine 6.3% had “basilar-type migraine.”57 Sometimes it is difficult to distinguish between VM and migraine with brainstem aura. Onset of the vertigo in relation to the

Conclusion

Evaluation of children and adolescents with headache and dizziness should focus on distinguishing between OI syndromes such as POTS and NMH from vertigo. Early diagnosis using cost-effective and minimally invasive methods with a multimodal approach to treatment including trigger avoidance, nonpharmacologic, and pharmacologic strategies along with patient and family education is imperative in achieving good treatment outcomes.

Acknowledgments

Special thanks to Drs Amy Gelfand, Jonathan Johnson, and Philip Fischer for their insightful feedback.

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