Headache & Pain
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May. 06, 2022
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Benign paroxysmal vertigo is one of the most common etiologies of vertigo in the pediatric population. Its diagnostic criteria have been defined by the International Classification of Headache Disorders (ICHD). Though its characteristics are well-defined, its pathophysiology remains in question. This article looks to explain the history of benign paroxysmal vertigo and its common features, diagnostic criteria, prognosis, and differential diagnosis that should be considered in pediatric patients presenting with vertigo. Although there exists a paucity of data regarding treatment of benign paroxysmal vertigo, its management will also be discussed.
The most updated version of the International Classification of Headache Disorders, ICHD 3, has replaced “childhood periodic syndromes that are commonly precursors of migraine” with “episodic syndromes that may be associated with migraine.” This group of disorders includes recurrent gastrointestinal disturbance, benign paroxysmal vertigo, and benign paroxysmal torticollis. The new term still commonly affects children but is no longer limited to this population by diagnostic criteria (20). They are diagnosed in an otherwise healthy patient with a normal neurologic examination in between attacks (17).
Benign paroxysmal vertigo is described as a separate entity from vestibular migraine in ICHD-3. Benign paroxysmal vertigo is predominantly described in the pediatric population, whereas vestibular migraine develops in childhood as well as during adulthood (24). A unilateral throbbing headache may occur during attacks of benign paroxysmal vertigo but is not mandatory, whereas at least half of the episodes of vestibular migraine should be associated with a headache fulfilling migraine criteria. Essentially, the short duration of the vertigo attacks and a less prominent headache help distinguish benign paroxysmal vertigo from vestibular migraine. Benign paroxysmal vertigo is considered a precursor syndrome to migraine (20). The ICHD-3 “episodic syndromes that may be associated with migraine” section also contains benign paroxysmal torticollis, cyclical vomiting syndrome, and abdominal migraine. Benign paroxysmal positional vertigo is commonly confused with benign paroxysmal vertigo considering the similarity in their names. These conditions will be discussed further in the differential diagnosis section below.
• Benign paroxysmal vertigo is characterized by recurrent, brief attacks of vertigo occurring without warning and resolving spontaneously in otherwise healthy patients.
• Benign paroxysmal vertigo is one of the most common causes of vertigo in childhood, with most cases experiencing spontaneous remission.
• Patients with benign paroxysmal vertigo are likely to have a family history of migraine and have a higher risk of developing migraine in adolescence or adulthood compared to the general population.
• The diagnosis of benign paroxysmal vertigo is based on the clinical history and exclusion of other diagnoses such as posterior fossa tumors, cervical spine abnormalities, vestibular pathology, epilepsy, and metabolic disorders.
• Prevention and treatment of benign paroxysmal vertigo largely lacks sufficient evidence, though oral migraine preventive medications also frequently used.
Wyllie and Schlesinger introduced the term periodic disorder of childhood in 1933, describing recurrent episodes of pyrexia, headache, vomiting, and abdominal pain in children (45).
In 1964 Basser described benign paroxysmal vertigo of childhood as a variety of vestibular neuronitis (04). In 1967 Fenichel reported two siblings who displayed the syndrome and latter progressed into classical migraine, suggesting that benign paroxysmal vertigo of childhood was instead a form of migraine peculiar to childhood (15).
As knowledge of childhood headache and its phenotypic presentation advanced, it was possible to observe stronger association of periodic syndromes with adult migraine with and without aura (43). Even though the majority of studies available rely on small case series, they have consistently shown a higher prevalence of migraine in children diagnosed with benign paroxysmal vertigo compared to the general population (27; 05). Similarities between children with benign paroxysmal vertigo and children with migraine support this common background with respect to social and demographic factors, precipitating and relieving factors, and accompanying gastrointestinal, neurologic, and vasomotor features (01; 37; 06).
Considering the similarities between benign paroxysmal vertigo of childhood and vestibular migraine, the Classification Committee of Vestibular Disorders of the Bárány Society and the International Headache Society have published a diagnostic criteria consensus document suggesting change in the terminology used to describe the syndrome (42). A slight change in diagnostic criteria comes with the alteration in terminology as well. For instance, they suggest changing the diagnosis from "benign paroxysmal vertigo of childhood” to "recurrent vertigo of childhood.” Patients must experience three episodes of vestibular symptoms lasting 1 minute to 72 hours to meet a diagnosis of recurrent vertigo of childhood. Severity must be moderate to severe in intensity, and the patient must lack both a history of migraine and any headache with their vestibular symptoms. The criteria for recurrent vertigo of childhood specifies that the patient is younger than 18 years old, which differs from the diagnostic criteria for benign paroxysmal vertigo of childhood.
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