The child
Paediatric vertigo
A child who is clumsy, hates the swings, walked late or struggles to read may be telling you about their vestibular system — in the only language they have.
How common, and why it is missed
Balance problems are more common in children than people think — about 1 in 20 children have dizziness or balance trouble. But young children can’t easily say “the room is spinning,” so it often gets put down to clumsiness or behaviour and is missed.
A population study found roughly 5.3% of US children (about 1 in 20) report dizziness or balance problems annually, highest in 12–17-year-olds and skewing female — paralleling the rise of vestibular migraine and post-concussive vestibulopathy in adolescence.1 It is under-recognised partly from a historical focus on hearing over balance, and partly because children present non-verbally.2
Certain groups are high-yield to screen: children with sensorineural hearing loss (up to ~70% have coexisting vestibular hypofunction), inner-ear malformations, syndromic conditions (e.g. Usher), recurrent otitis media, developmental delay, or traumatic brain injury.4 In referral-based balance clinics, around 8% of children seen for dizziness have a definable vestibular pathology — so vestibular screening in these populations turns otherwise-missed cases into treatable ones.3
The age-specific differential
The paediatric causes split into peripheral and central, and the child’s age narrows the field — BPVC in the 2–7 year-old, vestibular migraine in the school-age child and adolescent.5,6 Filter the differential below by locus; the central causes are flagged because they are the ones that must not be missed.
Paediatric vertigo — differential explorer
10 of 10- Vestibular migraineSchool-age & adolescents
Commonest cause of episodic vertigo; minutes–hours, ± photophobia/phonophobia. Headache may be absent in children. Family history of migraine; motion sensitivity.
- Benign paroxysmal vertigo of childhood (BPVC)2–7 years
Sudden, brief vertigo (seconds–minutes) ± pallor, nausea, nystagmus, with complete recovery between spells and normal exam. A migraine precursor — often evolves into vestibular migraine.
- Vestibular neuritis / labyrinthitisAny (uncommon in young children)
Acute, prolonged vertigo after a viral URTI; neuritis spares hearing, labyrinthitis adds hearing loss. Early rehabilitation aids compensation.
- Bilateral vestibulopathyInfancy onward
Congenital SNHL, inner-ear malformation or ototoxicity (aminoglycosides). Delayed motor milestones, poor balance, oscillopsia. Up to 70% of congenital SNHL has vestibular loss.
- Otitis media with effusionToddlers & young children
Chronic effusion can transiently impair balance and delay motor milestones; ventilation tubes may restore balance as well as hearing.
- Perilymphatic fistulaAny (trauma/congenital)
Vertigo on Valsalva, straining or loud sound (Tullio), ± progressive hearing loss. Consider after barotrauma or with inner-ear malformation.
- Posterior-fossa tumourred flagAny
Medulloblastoma, ependymoma, astrocytoma compressing brainstem/cerebellum — vertigo, gait ataxia, nystagmus, and raised-ICP signs (morning headache, vomiting, papilloedema). Image urgently.
- Chiari I malformationred flagAny
Positional vertigo and imbalance, headache worse on neck extension/Valsalva, downbeat nystagmus; may have syringomyelia/hydrocephalus. MRI diagnostic.
- Epileptic (vestibular) vertigored flagAny
Rare; stereotyped recurrent vertigo ± altered awareness or focal signs, usually temporal-lobe epilepsy. EEG and imaging clarify.
- Concussion / traumatic brain injurySchool-age & adolescents
Post-concussive dizziness, imbalance, visual-motion sensitivity and reading/concentration difficulty, often persisting weeks–months. Vestibular rehabilitation is key.
The non-verbal presentation
Because young children lack the words for vertigo, recognition depends on reading indirect signs — reported by parents and teachers as much as elicited in clinic:
- Delayed motor milestones — late sitting, crawling or walking
- Clumsiness, frequent tripping, wide-based or unsteady gait
- Motion intolerance — car sickness, dislike of swings/roundabouts
- Reading difficulty, losing place, poor copying from the board (visual–vestibular)
- Avoidance of movement-based play; fearfulness, irritability or withdrawal
- Being mislabelled as inattentive, anxious, ADHD or 'just behavioural'
The stakes are developmental, not just symptomatic: impaired visual–vestibular integration can slow reading and spatial learning, and untreated deficits can carry into adolescence — which is why oscillopsia and reading difficulty deserve a vestibular thought.7,8
Key points
- ~5% of children have dizziness/balance problems annually; highest in adolescence.
- Screen high-risk groups: SNHL, inner-ear malformation, syndromes, recurrent OME, developmental delay, head injury.
- Age narrows the differential: BPVC (2–7 y) and vestibular migraine (school-age/adolescent) dominate.
- Always flag central red-flags — posterior-fossa tumour, Chiari, epileptic vertigo.
- Recognition is non-verbal: motor delay, clumsiness, motion intolerance, reading and behavioural difficulty.