Dizziness and Vertigo in the Adolescent

The Adolescent Brain

Adolescence, the developmental transition between the dependency of childhood and the independency of adulthood, encompasses the approximate period between 12 and 18 years of age. Behavior during this developmental stage is frequently characterized by risk taking, impulsivity, and poor choices. The indestructible attitude of the adolescent, which can be met by negative consequences, promotes experimentation of adult practices, development of self-esteem, and eventually social acceptance.

Although the brain reaches 90% of its adult size by 6 years of age, pruning (resulting in decreasing synaptic density) and cortical thinning occur throughout childhood and adolescence. The volume of white matter continues to increase until approximately 20 years of age and is the result of ongoing myelination of white matter tracts. One of the last regions to undergo maturational processes is the prefrontal cortex, the region of the brain that participates in executive, attentional, and regulatory functions.

Adolescence represents a unique period of brain development marked by changes in neuroconnectivity and functional activation. Casey and colleagues suggested that the differential developmental trajectories of the limbic system and subcortical structures (e.g., basal ganglia) as compared with the prefrontal cortex could, in part, explain the impulsivity and risk-taking behavior that occur during adolescence. In their model, earlier maturation of the limbic system and subcortical structures during adolescence drives the adolescent behavior. As connections of the prefrontal cortex mature, influence of the limbic system and subcortical structures is reduced and the prefrontal cortex dominates, resulting in improved ability to suppress impulses and greater emphasis on goal-driven choices. Their model is supported by recent demonstrations of an exaggerated response of the nucleus accumbens in the adolescent as compared with the adult and child in a task that manipulated reward values, and correlation of the development of fiber tracts between the prefrontal cortex and basal ganglia with performance on a go/no-go task, a measure of inhibitory control.

Vertigo represents the sensation of inappropriate or abnormal motion and can be related to dysfunction of the vestibular system. Although morphologic development of the vestibular system is complete by term gestation, studies of the development of postural balance suggest that functional maturation of the vestibular system is ongoing during childhood and adolescence (see Chapter 3 ). For example, Steindl and colleagues used the sensory organization subtest of computerized dynamic posturography to measure postural stability in 140 children aged 3.5–16 years without known peripheral or central vestibular, proprioceptive, or visual disorders or medications that could affect balance. They observed increasing maturation of the vestibular afferent system up to 16 years of age. Their findings were in contrast to those of a prior study suggesting that vestibular development was not complete by 16 years of age. However, Steindl and colleagues observed reduced vestibular influence on postural control in adults as compared with the 15- to 16-year-old age groups. Cumberworth and colleagues suggested that the late functional development of the vestibular system as compared with the somatosensory and visual control of balance may explain differential rates of motion sickness in children and adolescents as compared with adults.

Vertigo and Dizziness in the Adolescent

Vertigo and dizziness are not synonymous terms, although they are often used interchangeably. Individuals with vertigo will often describe a rotational or room-spinning sensation. They may feel as though they are on a carousel or bobbing in a boat. Nausea and vomiting are often associated complaints. True vertigo implies an equilibrium disturbance associated with dysfunction of either the central or peripheral vestibular system. In contrast, dizziness is a term that may be used by patients to describe a distorted perception of the environment associated with etiologies that range from true vertigo to imbalance to presyncope to somatoform disorders. The majority of adults who presented to emergency departments (EDs) in the United States between 1993 and 2005 with a chief complaint of dizziness did not have a vestibular disorder and ultimately were diagnosed with cardiovascular, neurologic, or metabolic/toxic illnesses.

Complaints of dizziness and vertigo are common in the general population, occurring more frequently in women and those older than 60 years. In a review of National Hospital Ambulatory Medical Care Survey data of persons who presented to the ED with a chief complaint of vertigo/dizziness or the final diagnosis of a vestibular disorder, 16- to 19-year-old patients represented the smallest fraction. More recently, Li and colleagues used data from the 2012 National Health Interview Survey, which included a total of 10,954 children to study the prevalence of dizziness and balance problems in children aged 3–17 years (mean = 10.2 years) and found that the overall prevalence for the year analyzed was 5.3%, with a higher incidence in children aged 12–17 years (6.8%). When further classified, vertigo prevalence was 2.8% for adolescents (twice that of younger children), whereas the prevalence of lightheadedness was 3.7%. These authors noted a consistent age-related increase in the prevalence of dizziness and balance problems.

In contrast, population-based studies suggest that episodic vertigo and dizziness may be more common during adolescence than initially proposed. Russell and Abu-Arafeh provided a screening questionnaire to 2165 children ranging in age from 5 to 15 years who attended school in the city of Aberdeen, Scotland. Of the children surveyed, 314 (14%) reported at least one episode of dizziness in the previous year and 92 children (4%) reported three or more episodes of dizziness. Although complaints of dizziness occurred at all ages in this study, it was more common in adolescents, with a peak onset at 12 years of age. In contrast, Niemensivu and colleagues, based on prospective polling of children and adolescents ranging in age from 1 to 15 years, found that 8% (75 of 938) experienced an episode of vertigo or dizziness at some point during their life, predominantly between 11 and 15 years of age. These studies and future studies that attempt to define the true prevalence of vertigo and dizziness during childhood and adolescence have many potentially confounding variables: young children and adolescents may have difficulty accurately describing their symptoms; dizziness often resolves quickly in children and thus may be disregarded by the child or their family; and vertigo or dizziness may be reported by the adolescent or family as clumsiness. Furthermore, extrapolating findings in different populations may be difficult as prevalence may be influenced by environmental and genetic factors.

Vertigo and dizziness during adolescence can be the presenting symptom or, more typically, can be part of a complex of symptoms in a wide range of disorders that includes viral illnesses and intracranial tumors (see Box 6.1 ). In a hospital-based study, Fried reviewed medical records of all admissions to the Boston City Hospital for the 12-month period that spanned July 1976 to June 1977. The majority of adolescents admitted for dizziness during this period had experienced a concussion (4 of 9). This was also a common cause for dizziness and balance problems as reported by Li and colleagues.

In contrast, retrospective reviews of outpatient medical records of adolescents evaluated in either neurology or otolaryngology clinics consistently report vestibular migraine and benign paroxysmal vertigo of childhood (BPVC) as the most common causes of vertigo and dizziness in adolescents and children. For example, Weisleder and Fife reviewed charts of 31 children and adolescents ranging in age from 6 to 17 years who were referred for vestibular testing at a tertiary care center over a 6-year period. The majority of patients ( n = 11; 35%) were diagnosed with vestibular migraine. Other diagnoses included BPVC ( n = 6; 20%), anxiety attacks ( n = 3; 10%), Meniere’s disease ( n = 2), idiopathic sudden-onset sensorineural hearing loss ( n = 1), familial vertigo/ataxia syndrome (episodic ataxia type II, n = 1), and malingering ( n = 1).

In addition to vestibular migraine, these clinic-based studies have consistently observed a high incidence of depression and somatoform disorders among children and adolescents evaluated in these specialty clinics for complaints of vertigo or dizziness. For example, Ketola and colleagues reported that psychogenic vertigo accounted for 8% (9 of 119) of children and adolescents with the chief complaint of vertigo who were evaluated at the Otolaryngologic Clinic of Helsinki University Central Hospital between the years 2000 and 2004. Following psychiatric consultation, three children (aged 10 to almost 13 years) were diagnosed with depression; one adolescent (age 13.5 years) was diagnosed with a combination of conversion disorder, hyperventilation, and depression; one adolescent (age 15.6 years) was diagnosed with psychotic episode and depression; and the other four children (aged 9–11 years) were diagnosed with psychogenic headache, obsessive-compulsive disorder, panic disorder, or conversion disorder. Compared with children and adolescents who were identified as having an organic cause for vertigo, this group of children and adolescents had more frequent attacks or a complaint of constant vertigo, were more likely to suffer from school absenteeism, and were more likely to have dysfunctional relationships at school or at home. In addition, Emiroglu and colleagues found that 29 of 31 patients (93.5%) who presented to a pediatric neurology clinic for complaints of dizziness, headache, or fainting met criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for a psychiatric comorbidity, even when the primary diagnosis was some type of migraine headache.

Not all adolescents complaining of vertigo and dizziness will be referred for specialty clinic evaluation; therefore, many causes of dizziness in the adolescent are likely to be underreported in neurology and otolaryngology clinic-based studies. For example, complaints of vertigo or dizziness in the setting of concussion are likely to be principally managed by the pediatrician ; the child with dizziness in the setting of syncope or presyncope may be managed by the pediatrician or is more likely to be referred to a cardiologist than to a neurologist or to an otolaryngologist for further management; and the child with a brain tumor is most likely to be diagnosed in the ED and be managed by the oncologist, neuro-oncologist, and/or the neurosurgeon.