Vestibular migraine: a manifestation of long COVID syndrome in children

Abstract

Long COVID-19 syndrome has been reported among children and adolescents following COVID-19 recovery. Among them, notable symptoms include myalgia, insomnia, loss of smell and headache. Yet, novel manifestations are being discovered daily. Herein, we report two cases of vestibular migraine post-COVID-19 involving two children who presented with vestibular migraine symptoms following COVID-19 infection and their management. Children post-COVID-19 should be thoroughly evaluated for vestibular migraine symptoms so they can be managed promptly. This is the first article to report vestibular migraine as a manifestation of long COVID-19 syndrome.

Background

While most parts of the globe are entering an endemic phase of COVID-19, we are still left to deal with the aftermath of the disease: long COVID-19 syndrome. The WHO proposed the term ‘post-COVID-19 condition’ which is defined as a condition involving individuals with probable or confirmed SARS-CoV-2 infection,¹ 3 months from the onset of COVID-19 with symptoms that last for 2 months and cannot be explained by an alternative diagnosis.² Parallel to that, an International Classification of Disease (ICD) 10 code (U09.9) related to the post-COVID-19 condition has been formed.³ The SARS-CoV-2 infection resulted in symptoms involving nearly every human organ, both in children and adults.⁴ However, the clinical manifestations of long COVID-19 syndrome are still being investigated, with most studies involving adult patients. Reported clinical features of long COVID-19 syndrome include fatigue, dyspnoea, poor concentration and headache,⁵ which are similar in both adult and paediatric patients.^{6 7} We report two cases of vertiginous migraine post-COVID-19 involving children and their management. There are no similar cases published in the literature to date.

Case presentation

Case 1

A previously healthy girl in middle childhood presented with intermittent dizziness and headache. According to the child, dizziness is usually unprovoked, feels like swaying, occurs three to four times weekly, lasts around 20–30 min and is accompanied by a headache. Headache occasionally may precede giddiness and is unilateral or bilateral localised over the frontotemporal region with a severity index of 5–6, associated with photophobia. The symptoms often subside upon resting or lying down. Further history from parents revealed the symptoms precipitated following COVID-19 3 months prior. Before that, the child only had occasional episodes of a migraine-like headache without aura, which was relieved with analgesics. In addition to that, the child has severe motion sickness, especially when travelling far.

On examination, the otoscopic examination is unremarkable. The patient’s gait, oculomotor test, positional test and cerebellar sign are normal.

Case 2

A previously healthy boy in early adolescence presented with headaches and imbalance for the past 6 months. According to his parents, the symptoms began when the child tested positive for COVID-19 and have become more persistent. The child was noted to have almost daily episodes of headache, each lasting around 30–60 min, resolves with analgesic and occasionally requires repeated analgesic consumption. The nature of headache is usually bilateral, throbbing in nature around the temporal region, and associated with photophobia and phonophobia. Headache is frequently related to the feeling of imbalance or swaying. Upon further questioning, the parents claim the child has severe motion sickness, and he usually avoids using his handphone while sitting in the car. In addition, prior to this, he had occasional episodes of headache, which relieved with analgesics.

On examination, the child appears comfortable under room air. Otoscopic examination is unremarkable. The patient’s gait, oculomotor test, positional test, complete cranial nerve and neurological examinations were normal.

Investigations

Case 1

We performed cervical vestibular evoked myogenic potential (cVEMP), video head impulse test (vHIT), subjective visual vertical (SVV), dynamic visual acuity (DVA) and Fukuda stepping test (FST), which were all unremarkable. The patient was diagnosed with vestibular migraine of childhood as she fulfils the diagnostic criteria by the Barany Society.⁸

Case 2

He underwent the complete vestibular test, which includes cVEMP, vHIT, SVV, DVA and FST, which were all unremarkable. The patient was diagnosed with vestibular migraine of childhood.

Treatment

Case 1

Home-based vestibular rehabilitation focusing on adaptation and substitution protocol was taught to the child. Additionally, the child was advised to follow a strict, healthy lifestyle, including adequate sleep, stress avoidance and engaging in physical activity, and was started on supplements (tablet magnesium and tablet riboflavin). At the same time, parents were advised to monitor their child’s screen time and food habits. The child was advised to keep a diary of her symptoms. On subsequent review, the child claims her symptoms were well controlled with analgesics, which she takes only if required. Her daily lifestyle has improved tremendously, and her symptoms are also well controlled.

Case 2

The patient was started on tablet flunarizine 5 mg daily. The patient was also advised to do lifestyle modifications and home-based vestibular rehabilitation focusing on habituation protocol. His parents were advised to monitor their child’s screen time and food habits. In addition, the child was advised to keep a diary of his symptoms.

Outcome and follow-up

Case 1

On subsequent review, the child claims her symptoms were well controlled with analgesics, which she takes only if required. Her daily lifestyle has improved tremendously, and her symptoms are also well controlled.

Case 2

After a subsequent review in 1 month, the child claims his symptoms were well controlled with tablet flunarizine. He only required additional analgesics during two episodes, which resolved after 15 min of oral analgesic. The patient claims his quality of life has improved dramatically. He was advised to continue taking tablet flunarizine for another 3 months prior to his review.

Discussion

Ever since the association between vestibular symptoms and migraine was first described in 1984 by Kayan and Hood, numerous articles and studies on vestibular migraine have emerged involving both adults and, more recently, children and adolescents.⁹ Vestibular migraine entails the occurrence of migrainous headache along with either vertigo or non-specific dizziness.⁸ Reported risk factors of vestibular migraine include motion sickness and having a first-degree relative with migraine. However, compared with adults, children typically struggle to express their symptoms accurately, which could delay diagnosis.

According to the recent meta-analysis by Lopez-Leon et al, the prevalence of long COVID-19 in children was 25.24%, with mood symptoms (16.5%), fatigue (9.66%) and sleep disorders (8.42%) reported as the most prevalent manifestations, whereas headache and dizziness have been reported to be 7.84% and 4.4%, respectively.¹⁰ Non-specific symptoms such as giddiness¹¹ and migraine-like symptoms¹² have been widely reported among children following recovery from COVID-19, although the exact pathophysiology remains unclear. The risk factors for developing long COVID-19 syndrome are still being studied. Interestingly, the severity of SARS-CoV-2 infection is not a risk factor as children inflicted with mild SARS-CoV-2 infection have demonstrated symptoms of long COVID-19.¹³ Nonetheless, older children appeared to be more predisposed to developing long COVID-19 syndrome than the younger ones.¹⁴

No published article has reported vestibular migraine as a manifestation of long COVID-19 syndrome. The pathomechanism of vestibular migraine in children and adults has been linked to altered neural activity within the trigeminovascular system (TVS).¹⁵ Substance P and the calcitonin gene-related peptide, the main neuropeptides of the TVS that contribute to the vasodilation and neurogenic inflammation causing headaches, are also expressed in the vestibular system, which leads to dizziness.¹⁵ Parallel to that, we know that neuropeptides such as substance P have been found to be elevated in patients with COVID-19.¹⁶ We postulate that the elevated neurotransmitters triggering the TVS could have led to vestibular migraine in the children with COVID-19, although it is still at a hypothesis stage. On another note, stress, a known trigger of vestibular migraine, which has affected the children infected with SARS-CoV-2, may also have resulted in vestibular migraine manifestations. It is also worth noting that infection-induced vestibular migraine has not been reported in children, although the possibility is believed to be secondary to inflammatory mediators.

Vestibular migraine is a clinical diagnosis that follows the diagnostic criteria consensus document of the Classification Committee of Vestibular Disorders of the Barany Society and the International Headache Society.⁸ Children and adolescents with vestibular migraine classically present with either dizziness or spinning sensation associated with headache, although the episodes of headache may occur on separate occasions, which are reported by both of our patients. Both of our patients fulfil the criteria for vestibular migraine of childhood⁸ as they had at least five episodes of headache and vestibular symptoms of moderate intensity lasting more than 5 min and were not accounted for by any other diagnosis. Moreover, both these children have prior episodes of headache, although the headache was not debilitating.

Vestibular migraine is typically diagnosed based on the clinical description of symptoms along with the exclusion of other potential causes using appropriate investigation, including neuro-otological assessments such as vestibular and audiometric assessments as well as imaging.

The long-term outcome of symptoms from long COVID-19 syndrome remains unexplored. Patients with COVID-19 with headaches or dizziness, which persisted longer than 2 months, were observed to continue having symptoms over longer duration. Although the uncertainties remain, it is imperative to manage children with post-COVID-19 vestibular migraine as it can severely impact their quality of life. Early vestibular rehabilitation, as well as lifestyle modifications, may aid in controlling and alleviating symptoms among children. On the contrary, pharmacological treatment to alleviate and control symptoms in children is to be commenced if non-pharmacological treatments fail or if the severity of symptoms significantly impairs the child’s overall quality of life. Both the children discussed recovered following proper management. Following the uncertainty around the manifestation of long COVID-19 in children, a thorough multidisciplinary evaluation is required during the follow-up.

Learning points.

• Reports on various long COVID-19 symptoms are emerging involving both adults and children.

• Vestibular migraine, which encompasses both headache and dizziness, has been reported to involve children, and its pathomechanism remains elusive.

• Vestibular migraine has been reported in two children, which was triggered by COVID-19 infection, and symptoms remain persistent for months post-COVID-19.

• Vestibular and neurological investigations should be carried out promptly to rule out other sinister conditions such as brain tumours.

• Early vestibular rehabilitation and lifestyle modifications have been demonstrated to improve symptoms and overall quality of life among the affected children.

Ethics statements

Patient consent for publication

Obtained.