The child

Paediatric assessment & care

The work-up has to fit the child, not the other way round — a developmentally-tailored history, an examination disguised as play, and rehabilitation that feels like a game.

A developmentally-tailored work-up

Diagnosis rests first on a careful history adapted to the child’s age — onset, duration and triggers of episodes; associated hearing loss, headache or nausea; and the developmental history (age of sitting, crawling, walking) and school performance, which flag bilateral hypofunction and visual–vestibular difficulty.1

Examination focuses on oculomotor and postural function: spontaneous, gaze-evoked and positional nystagmus; head impulse; and bedside balance (Romberg, tandem gait, single-leg stance), with dynamic visual acuity where the child can cooperate. Targeted testing adds audiometry and tympanometry, VNG, vHIT (brief and well-tolerated by older children),2 VEMPs, and rotary chair for the youngest or least cooperative. MRI is reserved for suspected central pathology, and temporal-bone CT for malformation or trauma.

Condition-specific management

  • Vestibular migraine — lifestyle and trigger management first; prophylaxis when needed (cyproheptadine in young children; propranolol, amitriptyline or flunarizine in older children), plus rehabilitation for interictal imbalance.3
  • BPVC — reassurance and observation; no drug treatment. Follow up, as some children later develop vestibular migraine.
  • Vestibular neuritis / labyrinthitis — short-term antiemetics and hydration, then early rehabilitation; steroids are not well-evidenced in children and reserved for severe cases.
  • Otitis media with effusion — treat the middle-ear disease; ventilation tubes can improve balance and motor function as well as hearing in persistent cases.4
  • Bilateral vestibulopathy — no drug cure; intensive, sustained rehabilitation with visual/proprioceptive substitution, fall-prevention and school accommodations.5
  • Concussion — graded vestibular rehabilitation, watching for symptom exacerbation, plus school accommodations.7

Play-based vestibular rehabilitation

Vestibular rehabilitation is the therapeutic backbone, engaging central neuroplasticity through gaze-stabilisation, habituation, balance and postural-control exercises. In children it must be age-appropriate and play-based — framed as games, obstacle courses and interactive video — with strong caregiver involvement to sustain home practice. Structured programmes improve postural control and motor function, including in children with SNHL and vestibular impairment, and reduce dizziness and improve school participation in vestibular migraine and post-traumatic dizziness.5,6

Prognosis: BPVC and vestibular migraine generally do well; bilateral and congenital deficits carry a higher risk of persistent motor delay and academic difficulty, and central causes depend on the underlying disease. Early, tailored, multidisciplinary care is the strongest predictor of a good outcome.

Key points

  • History must include developmental milestones and school performance, not just the episodes.
  • Examination is oculomotor + postural; vHIT, VEMP and rotary chair adapt testing to age.
  • Image (MRI) only for suspected central pathology; CT for malformation/trauma.
  • Management is condition-specific; OME may need tubes, bilateral loss needs intensive rehab.
  • Vestibular rehabilitation works — but only if it is play-based and caregiver-supported.