Retrospective Assessment of Clinical and Laboratory Features in Pediatric Neurology Patients Presenting with Vertigo

Abstract

Objective

It was aimed to retrospectively evaluate the clinical, laboratory, neuroimaging, and electrophysiological characteristics of children presenting with vertigo to a tertiary pediatric neurology outpatient clinic and to assess age-related differences in etiological diagnoses.

Methods

Medical records of 272 patients under 18 years of age who presented with vertigo between January 2020 and January 2025 were reviewed. Demographic data, accompanying symptoms, neurological examination findings, laboratory results, electroencephalography (EEG) and magnetic resonance imaging (MRI) reports, consultations, and final diagnoses were collected. Patients were categorized as children (<12 years) or adolescents (≥12 years). Descriptive statistics and appropriate comparative tests were used.

Results

The mean age of patients was 12.73±3.68 years; 67.6% were female. The most common accompanying symptoms were visual blackouts (22.1%), headaches (16.2%), nausea and vomiting (11.4%), and syncope (9.2%). Neurological examination was normal in 97.4% of cases. MRI was performed in 84.6% of cases and showed abnormalities in 21.3%; most abnormalities were non-specific, while 4.8% had clinically relevant lesions. EEG was abnormal in 6.3% of cases. The most frequent diagnoses were orthostatic hypotension (23.5%), vestibular migraine (13.6%), psychogenic vertigo (12.9%), benign paroxysmal vertigo of childhood (BPVC) (8.5%), and epilepsy (6.3%). BPVC and epilepsy were more common among children, whereas orthostatic hypotension and psychogenic vertigo were more common among adolescents. No etiology was identified in 13.6% of patients.

Conclusions

Most pediatric vertigo cases were benign, with clear age-specific diagnostic patterns. MRI and EEG contributed to the diagnosis in selected cases, but were largely nonspecific. Multidisciplinary evaluation, including assessment of orthostatic intolerance, migraine, psychogenic factors, and reversible metabolic causes, is essential for effective management.

INTRODUCTION

Vertigo is defined as an illusory sensation of motion, typically experienced as a feeling that the environment or the individual is spinning. In children, vertigo is a relatively uncommon but clinically significant symptom, and its evaluation is often challenging due to age-related limitations in verbal expression and symptom description^{1, 2}.

Although the prevalence of vertigo is lower in children than in adults, it is not rare. Epidemiological studies have reported a prevalence ranging from 2% to 7%, with a noticeable increase during adolescence, possibly due to hormonal changes and the maturation of the vestibular system^{3, 4}.

The most commonly reported causes of vertigo in the pediatric population include benign paroxysmal vertigo of childhood (BPVC), vestibular migraine, epileptic vertigo, and psychogenic dizziness⁵. These conditions differ in clinical presentation, age of onset, and associated features. For example, BPVC is predominantly seen in preschool-aged children, while vestibular migraine is more frequently diagnosed in adolescents, especially in females^{2, 6}.

In the clinical setting, pediatric vertigo requires a structured diagnostic approach, including comprehensive history-taking (onset, duration, frequency, and triggers), neurological and vestibular examinations, and ancillary investigations such as audiometry, electroencephalography (EEG), magnetic resonance imaging (MRI), or vestibular function tests, depending on the suspected etiology⁷. Despite this, the evaluation of pediatric vertigo is often delayed or misattributed, particularly in non-specialized settings, because of its low incidence and overlap with behavioral or psychiatric symptoms⁴.

In recent years, several studies have emphasized that the early recognition and classification of vertigo in children are crucial for preventing unnecessary diagnostic procedures and improving long-term quality of life^{6, 8}. A timely diagnosis not only facilitates targeted therapy but also helps prevent school absenteeism, anxiety, and psychosomatic consequences that frequently accompany recurrent dizziness⁹.

Moreover, regional and institutional differences in clinical experience result in considerable variability in diagnostic approaches and reported etiologies¹⁰. This variability may also be attributed to differences in patient populations across departments —such as pediatric neurology, cardiology, or otolaryngology— as well as to the diversity of clinical cases, variations in study design, age distribution, clinical evaluation methods, and inclusion criteria⁸. In developing countries, retrospective data from pediatric neurology outpatient clinics remain limited, underscoring the need for standardized, population-specific clinical information¹⁰.

Furthermore, most existing studies have been conducted in otolaryngology settings, whereas data from pediatric neurology departments remain relatively scarce¹¹. Given that many vertigo cases in children may originate from neurological causes —such as migraine variants, epileptic phenomena, or central lesions— neurological evaluation plays a critical role in identifying the underlying etiologies^{6, 12}. Therefore, a multidisciplinary assessment that combines neurological, vestibular, and psychological perspectives is strongly recommended¹³.

This study retrospectively evaluates the demographic, clinical, neurological, laboratory, and diagnostic characteristics of pediatric patients who presented to a tertiary pediatric neurology outpatient clinic with vertigo. Specifically, the study seeks to identify the spectrum of etiological diagnoses, assess age-related differences, and analyze the contributions of neuroimaging and electrophysiological investigations to clinical diagnosis. The ultimate objective is to enhance the understanding of pediatric vertigo and provide supportive data to the existing literature in this underrepresented area.

MATERIAL and METHODS

Study Design and Population

This retrospective cross-sectional study evaluated the clinical and demographic characteristics of pediatric patients who presented to the Pediatric Neurology Outpatient Clinic of Istanbul Medipol University with vertigo. The medical records of patients younger than 18 years who presented with symptoms of vertigo from January 2020 to January 2025 were reviewed.

The inclusion criteria were as follows:

• age <18 years at the time of evaluation,

• presentation with vertigo or dizziness as a primary complaint,

• at least one documented episode of vertigo,

• evaluation in the pediatric neurology outpatient clinic during the study period,

• availability of sufficient clinical data to allow diagnostic assessment, including age, sex, associated symptoms, neurological examination findings, and a final documented diagnosis.

Patients were excluded from the study based on the following criteria:

• incomplete or unavailable medical records preventing adequate clinical evaluation,

• significant cognitive or motor developmental delay,

• history of long-term medication use that could affect neurological or vestibular assessment,

• duplicate visits related to vertigo (only one eligible visit per patient was included),

• cases in which vertigo-related evaluation could not be completed due to insufficient documentation.

Between January 2020 and January 2025, a total of 26,788 pediatric patients were evaluated in the Pediatric Neurology Outpatient Clinic. Among these patients, 1,090 (4.1%) presented with vertigo or dizziness as a primary complaint. After removal of duplicate visits, 619 unique patients with vertigo were identified. After applying the predefined inclusion and exclusion criteria, 347 patients were excluded. The final study population consisted of 272 patients. The patient selection process is summarized in a flow diagram (Figure 1).

Figure 1.

Flow diagram of patient selection.

All patients evaluated in the pediatric neurology outpatient clinic were examined during the interictal period (i.e., outside the acute vertigo episode).

This study followed a retrospective cross-sectional design and aimed to analyze demographic and clinical variables collected from medical records at a single time point for all eligible cases. Data extraction and review were performed using a standardized clinical data collection form to ensure consistency across cases.

Data Collection

Data collected from patient files included the following variables: age, sex, duration of vertigo episodes, accompanying symptoms (e.g., headache, nausea, vomiting, syncope, and balance disturbances), family history of migraine, epilepsy, or vertigo, findings from neurological, audiological, ophthalmological, and psychiatric evaluations, results of brain MRI and EEG, laboratory test results (including vitamin B12, complete blood count, thyroid function tests, and liver and renal function tests), final clinical diagnoses, and follow-up durations.

Clinical data were obtained retrospectively from the hospital’s central electronic database. Patients were identified in the institutional medical record system by querying for those who received a vertigo-related diagnosis during evaluation at the Pediatric Neurology Clinic. All data were retrieved from this centralized digital database. No data were extracted from hard-copy records or separate archival files.

Vertigo duration, frequency, and triggering factors were extracted from the clinical notes when available. For patients who underwent follow-up evaluations, persistence of symptoms or changes in diagnosis were also recorded.

Diagnostic Procedure

Diagnostic evaluations were performed according to the presenting symptoms and clinical suspicion. Each patient underwent a detailed neurological examination, including assessment of gait, balance, coordination, and cranial nerve function.

Audiological and vestibular examinations were requested for patients with suspected peripheral vertigo or hearing abnormalities. Although the Head Impulse, Nystagmus, and Test of Skew (HINTS) test was performed in some patients evaluated by the otolaryngology department, detailed documentation was not consistently available in the patient records.

Patients with pathological findings on vestibular function tests (e.g., HINTS) suggesting peripheral vertigo were excluded from the study.

EEG was performed in cases where epileptic vertigo, syncope-like episodes, or paroxysmal events were suspected. Brain MRI was obtained for patients with prolonged or recurrent vertigo, abnormal neurological findings, or suspected central nervous system pathology.

Some MRI examinations were performed in pediatric outpatient settings or during emergency department evaluations prior to referral to the pediatric neurology clinic.

Laboratory tests were ordered to rule out metabolic or systemic causes such as anemia, thyroid dysfunction, or vitamin deficiencies.

Clinical Diagnostic Algorithm

Based on routine clinical practice in the pediatric neurology outpatient clinic, a diagnostic flowchart was constructed to summarize the evaluation and decision-making process for pediatric patients presenting with vertigo (Figure 2). All patients underwent a standardized initial assessment including detailed clinical history, neurological examination during the interictal period, and baseline laboratory investigations to screen for metabolic or systemic causes. Neuroimaging (MRI) and EEG were subsequently performed on selected patients based on clinical suspicion, such as prolonged or recurrent vertigo, abnormal neurological findings, or paroxysmal events. Specialist consultations (ENT, cardiology, ophthalmology, and psychiatry) were requested selectively, as indicated by accompanying symptoms and preliminary findings. Patients with evidence of peripheral vestibular pathology were excluded. Final diagnoses were established after completion of the diagnostic workflow, incorporating investigation results, consultation outcomes, and multidisciplinary clinical judgment.

Figure 2.

Clinical diagnostic algorithm for pediatric patients presenting with vertigo.

MRI: Magnetic resonance imaging, EEG: Electroencephalography, ENT: Ear, nose, and throat (otolaryngology), BPVC: Benign paroxysmal vertigo of childhood.

Diagnostic Classification Criteria

Patients were categorized based on the clinical diagnoses documented during routine outpatient evaluations. These diagnoses included BPVC, vestibular migraine, psychogenic vertigo, and epileptic vertigo.

Patients were also divided into two age-based subgroups: children (<12 years) and adolescents (≥12 years). A cut-off age of twelve years was used to distinguish children from adolescents, reflecting developmental stages that may influence symptom presentation and diagnostic variability. This threshold was chosen in line with established developmental frameworks, as adolescence is commonly defined as the 10-19-year age group by the World Health Organization, and pediatric frameworks frequently describe early adolescence as beginning around 11-12 years¹⁴. An age threshold of 12 years was chosen because pubertal staging data were not available in the medical records; therefore, a clear distinction between prepubertal and pubertal stages could not be made. In addition, population-based clinical references indicate that the average age at the onset of puberty is approximately 11 years in girls and 12 years in boys, supporting the clinical relevance of using 12 years as a pragmatic proxy for pubertal transition in retrospective datasets¹⁵.

BPVC was diagnosed in patients who had brief, self-limited vertigo episodes and normal neurological and EEG findings between episodes. This condition is recognized by the International Classification of Headache Disorders, 3^rd edition, as a childhood migraine precursor¹⁶.

Vestibular migraine was identified in cases in which vertigo episodes were accompanied or followed by migraine-like headaches. The diagnostic concept of vestibular migraine is supported by consensus criteria jointly developed by the Bárány Society and the International Headache Society¹⁷.

Psychogenic vertigo was defined in patients presenting with vertigo or dizziness who had a normal neurological examination and no evidence of peripheral vestibular pathology on clinical assessment and/or otolaryngology evaluation when performed. Cases were classified as psychogenic when symptoms were temporally associated with psychosocial stressors or anxiety-related triggers, no alternative organic etiology could be established after routine clinical work-up (including laboratory tests, MRI, or EEG when clinically indicated), and psychiatric evaluation supported a functional or psychogenic contribution^{7, 18}.

Epileptic vertigo was diagnosed in patients who exhibited recurrent paroxysmal vertigo suggestive of a seizure-related phenomenon (e.g., stereotyped attacks or transient impairment of awareness) and epileptiform abnormalities on routine interictal EEG in the absence of an alternative explanation. This classification was aligned with the concept of focal sensory vestibular seizures as described in the International League Against Epilepsy diagnostic framework^{19, 20}. In this study, both compatible clinical manifestations and EEG abnormalities were required for diagnosis, and EEG findings alone were not considered sufficient¹⁹.

In cases with overlapping features or uncertain etiologies, final diagnoses were determined through multidisciplinary discussions among pediatric neurologists, psychiatrists, and otolaryngologists.

Statistical Analysis

All statistical analyses were performed using IBM SPSS Statistics for Windows, version 24.0. The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Continuous variables were summarized as mean ± standard deviation for normally distributed data and as median (minimum-maximum) for non-normally distributed data, while categorical variables were presented as frequencies and percentages.

Group comparisons were performed using the independent-samples t-test for normally distributed continuous variables and the Mann-Whitney U-test for non-normally distributed continuous variables. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. A p-value <0.05 was considered statistically significant.

In addition to p-values, effect sizes were calculated to estimate the magnitude of statistically significant findings. Cohen’s d was used for comparisons involving the independent-samples t-test; r values were calculated for Mann-Whitney U-tests; and Cramér's V was reported for categorical comparisons.

A post-hoc power analysis was conducted based on the final sample size (n=272). For a two-sided test at an alpha level of 0.05, the study demonstrated statistical power greater than 80% to detect medium effect sizes, indicating that the sample size was adequate for the primary analyses.

Ethical Considerations

The study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Ethical approval for this study was obtained from the Ethics Committee of Medipol University (Non-Interventional Clinical Research Ethics Committee on with decision number: 464, date: 17.04. 2025.

RESULTS

Demographic Characteristics

A total of 272 pediatric patients presenting with vertigo were included in the study. The mean age of the participants was 12.73±3.68 years (range: 2.08-17.88 years), and 67.6% (n=184) were female. The median duration of vertigo symptoms was 5 months (range: 0.25-72 months).

Of all participants, 98 (36.0%) were younger than 12 years, and 174 (64.0%) were adolescents aged 12 years or older.

Clinical Features

The most common accompanying symptoms were visual blackouts (22.1%, n = 60), headache (16.2%, n=44), nausea and vomiting (11.4%, n=31), and syncope (9.2%, n=25). Other reported symptoms included tinnitus (7.0, n=19), balance disturbances (4.4, n=12), and blurred vision (3.7, n=10). The neurological examination was normal in 97.4% (n=265) of the cases, while pathological findings were observed in only 2.6% (n=7). Vertigo episodes were transient and self-limiting in most patients; however, 36 patients (13.2%) experienced recurrent attacks lasting longer than three months.

Laboratory Findings

Laboratory findings revealed a mean hemoglobin level of 13.3±1.3 g/dL, consistent across both age groups. Vitamin B12 levels were reported as medians because of a non-normal distribution: 414 pg/mL (range: 110-1511) in children and 352 pg/mL (range: 163-1099) in adolescents. Sodium levels were reported as medians and did not differ significantly between groups (139 mmol/L in both groups). Vitamin B12 deficiency was identified in 12.5% (n=34) of the patients, while anemia was observed in 0.7% (n=2).

Imaging and Electrophysiological Findings

Among imaging and electrophysiological studies, cranial MRI was performed in 230 patients (84.6%), revealing abnormal findings in 49 patients (21.3%), of whom 36 (13%) were considered non-specific. These included non-specific gliosis, arachnoid cysts, ventricular asymmetry, pineal cysts, and other incidental findings.

Thirteen patients (4.8%) were found to have vertigo secondary to underlying lesions detected on imaging. The median duration of vertigo in patients with MRI-detected lesions was 2 months (range: 0.5-24 months). Some MRI scans were performed prior to referral, either in the pediatric outpatient setting or during the initial evaluation at the emergency department.

EEG was performed in 95 patients (34.9%) and showed abnormal results in 17 patients (6.3%).

Diagnostic Distribution

Vertigo-related diagnoses included vestibular migraine in 13.6% (n=37), psychogenic vertigo in 12.9% (n=35), BPVC in 8.5% (n=23), and epilepsy in 6.3% (n=17). Vitamin B12 deficiency was present in 12.5% (n=34), anemia in 0.7% (n=2), and orthostatic hypotension in 23.5% (n=64). A history of trauma was reported in 1.8% (n=5). A total of 13 patients (4.8%) were found to have vertigo secondary to underlying lesions detected on imaging. In 13.6% of cases (n=37), the cause of vertigo remained unknown despite clinical and diagnostic evaluation.

Table 1 presents the distribution of brain lesions detected on MRI, including lesions associated with specific neurological disorders (13 of 230 patients, 5.6%). Specifically, the brain tumors were predominantly located in the posterior fossa, the cavernoma involved the brainstem, and the mitochondrial lesion involved the basal ganglia.

Table 1. The brain lesion related to specific neurologic disorders on MRI examinations.

Lesion type	Patients (n=13/230, 5.6%)
Brain tumor	3 (1.3%)
Multiple sclerosis	3 (1.3%)
Cerebellar infarction	1 (0.4%)
Cerebellar encephalomalacia	1 (0.4%)
Type 1 Chiari malformation	2 (0.9%)
Cavernoma	1 (0.4%)
Cerebellar venous anomaly	1 (0.4%)
Mitochondrial disease	1 (0.4%)

MRI: Magnetic resonance imaging

Age-Based Comparison

The cohort was divided into two groups based on age: children under 12 years (n=98, 36.0%) and adolescents aged 12 years and above (n=174, 64.0%). Psychogenic vertigo was more common among adolescents (15.5% n=27) than younger children (8.2% n=8), although this difference did not reach statistical significance (p=0.082). Orthostatic hypotension was significantly more frequent in adolescents (31.6% n=54 vs. 9.2% n=9, p<0.001), with a large effect size (Cramér's V =0.38), whereas epilepsy and BPVC were more common in children under 12 years of age (9.2% n= 9 vs. 4.6% n=8 and 19.4% n=19 vs. 2.3% n=4, respectively), representing moderate to large effect sizes (Cramér's V =0.21 for epilepsy and Cramér's V =0.41 for BPVC). No significant age-related differences were found in the frequency of vestibular migraine, B12 deficiency, or MRI abnormalities. Overall, effect size analyses of statistically significant comparisons indicated moderate-to-large magnitudes, supporting the clinical relevance of the observed age-related differences.

The clinical, laboratory, and symptomatic characteristics of children and adolescents with vertigo are summarized in Table 2, and the age-based distribution of vertigo diagnoses is illustrated in Figure 3.

Table 2. Clinical, laboratory and symptomatic characteristics of children and adolescents with vertigo.

Variable	Children(<12 years, n=98)	Adolescents(≥12 years, n=174)	p-value †‡§*
Sex (F/M)	58/40	126/48	0.025‡
Median duration of vertigo (months), median (min-max)	3 (0.25-48)	6 (0.25-72)	<0.001†
Vitamin B12 level (pg/mL), median (min-max)	414 (110-1511)	352 (163-1099)	0.004†
Hemoglobin (g/dL), mean (± SD)	13.08 ±1.16	13.46±1.40	0.162*
Sodium (mmol/L), median (min-max)	139 (135-143)	139 (132-149)	0.602†
Symptoms	-	-	-
Headache, n (%)	12 (12.2%)	32 (18.4%)	0.250‡
Nausea/vomiting, n (%)	13 (13.3%)	18 (10.3%)	0.597‡
Syncope, n (%)	5 (5.1%)	20 (11.5%)	0,125§
Visual blackout, n (%)	10 (10.2%)	50 (28.7%)	0.001‡
Blurred vision, n (%)	4 (4.1%)	6 (3.4%)	0.750§
Tinnitus, n (%)	5 (5.1%)	14 (8.0%)	0.505§

*: Independent Samples t-test, †: Mann-Whitney U test, ‡: Pearson’s chi-square test, §: Fisher’s Exact test

SD: Standard deviation

Figure 3.

Age-based distribution of vertigo diagnoses in pediatric patients.

The bar graph compares the frequency (%) of mutually exclusive vertigo diagnoses between children (<12 years) and adolescents (≥12 years). Each patient received only one final diagnosis. An overall significant difference was observed between the age groups (χ² (10)=46.13, p<0.001). *Indicates statistically significant differences between age groups for the corresponding diagnosis (p<0.05).

BPVC: Benign paroxysmal vertigo of childhood.

Consultations and Symptom Profiles

In addition to neurological evaluation, consultations from other specialties were requested when indicated. The distribution of diagnostic investigations and specialist consultations performed during the evaluation process is summarized in Table 3. Patients with confirmed peripheral vestibular disorders were excluded from the study; therefore, the ENT consultations included in the analysis represented cases with no detectable peripheral pathology. Pediatric cardiology consultations were performed in patients presenting with syncope, palpitations, or orthostatic symptoms. No structural cardiac pathology was detected during the cardiology consultations.

Table 3. Diagnostic investigations and consultation rates.

Investigation/consultation	n (%)
Laboratory tests (baseline, all patients)	272 (100)
Brain MRI	230 (84.6)
EEG	95 (34.9)
ENT consultation	56 (20.6)
Cardiology consultation	38 (14.0)
Ophthalmology consultation	12 (4.4)

This table summarizes the frequency of diagnostic investigations and specialist consultations performed during the evaluation of pediatric patients presenting with vertigo. Baseline laboratory tests were obtained in all patients, while MRI, EEG, and consultations were performed selectively based on clinical indications.

MRI: Magnetic resonance imaging, EEG: Electroencephalography, ENT: Ear, nose, and throat (otolaryngology)

Symptom profiles varied across diagnostic categories. Headache and tinnitus were most commonly associated with vestibular migraine, whereas syncope and visual blackouts were predominant in patients with orthostatic hypotension. As shown in Figure 4, nausea and vomiting were frequently observed across several diagnoses.

Figure 4.

Diagnosis-specific symptom distribution. The bar chart illustrates the distribution of specific symptoms across different diagnostic groups.

No statistically significant relationship was found between symptom type and sex distribution.

DISCUSSION

Vertigo is often an age-specific disease with a variety of etiology-specific diagnoses in childhood and adolescence. More etiology-specific diagnoses were established in the presented cohort following a diagnostic work-up that included neuroimaging and EEG recordings.  The most common diagnoses were orthostatic hypotension (23.5%), vestibular migraine (13.6%), psychogenic vertigo (12.9%), BPVC (8.5%), and epilepsy (6.3%). Structural brain lesions were detected in 21.3% of patients undergoing MRI (5.6% with brain lesions related to specific neurologic conditions). Psychogenic vertigo and orthostatic hypotension were more frequent in children aged >12 years. In contrast, BPVC and epilepsy were relatively more common in younger children. No definitive etiology was identified in 13.6% of the presented cohort.

The mean age of the patients in our cohort was 12.7 years, consistent with previous reports suggesting a higher incidence of vertigo complaints in the adolescent age group²¹.

Vertigo is more frequently observed in girls than in boys during childhood and adolescence. This female predominance has been consistently reported in both national and international studies. In our study, the female-to-male ratio was 2.09, which is slightly higher than the 1.94 ratio reported by Erbek et al.²² Similarly, Swain et al.²³ identified a female predominance with a ratio of approximately 1.57:1 in a pediatric cohort, while Li et al.²¹ observed a higher prevalence of dizziness among girls, particularly after the age of 10. The higher female predominance may reflect puberty-related hormonal changes or a greater tendency for symptom reporting among girls.

In our study, visual blackouts (22.1%, n=60) and headaches (16.2%, n=44) were the most frequently reported accompanying symptoms, followed by nausea/vomiting (11.4%, n=31) and syncope (9.2%, n=25). Similarly, Aydın et al.²⁴ reported headache in 57.4% and visual blackouts in 41.5% of pediatric patients with vertigo, highlighting the prominence of these symptoms in clinical presentations. Similar to our results, Erbek et al.²² also noted that headache and nausea were among the leading complaints in children. These findings emphasize that children may often express vertiginous sensations through more relatable symptoms such as visual disturbances or general discomfort rather than using precise vestibular terminology⁴. The neurological examination was normal in 97.4% (n=265) of our patients, supporting the common observation that pediatric vertigo is frequently of benign or functional origin⁷.

Vitamin B12 deficiency has been implicated as a contributing factor in pediatric vertigo. In the study by Aydın et al.²⁴, the mean serum vitamin B12 level was reported to be 198.6±83.8 pg/mL, notably below the commonly accepted lower threshold of 300 pg/mL for deficiency^{24, 25, 26}. In contrast, our study found a considerably higher mean B12 level of 407.7±211.9 pg/mL, likely reflecting variability in study populations and nutritional profiles. In our cohort, patients with B12 levels below 300 pg/mL who exhibited symptomatic improvement following vitamin B12 supplementation were classified as having vertigo related to B12 deficiency. This clinical approach emphasizes the importance of considering reversible metabolic causes in the diagnostic workup of pediatric vertigo. Although B12 deficiency was not the most prevalent etiology, its recognition is crucial, given that timely replacement therapy can lead to complete symptom resolution in affected individuals.

In our study, cranial MRI was performed in the majority of patients (84.6%, n=230), with abnormal findings detected in 21.3% of cases. However, most of these abnormalities (n=36) were nonspecific and included incidental findings, such as arachnoid cysts, pineal cysts, ventricular asymmetry, and nonspecific gliosis. These results are consistent with previous pediatric studies indicating that many MRI abnormalities in children with vertigo are not directly related to the presenting symptoms and often represent benign anatomical variations or incidental findings^{27, 28}. The relatively high neuroimaging rate in our cohort can be explained by the clinical characteristics of the referred population. MRI was primarily performed in patients with prolonged or recurrent vertigo, abnormal neurological findings, or suspected central causes. In addition, some MRI scans were performed prior to referral—either during the initial emergency evaluation or by general pediatricians—further contributing to the high imaging rate. Importantly, most of these imaging results were non-specific, supporting the need for a more selective, indication-based approach to neuroimaging in pediatric vertigo. Given the relatively high rate of non-specific imaging findings, routine neuroimaging for all pediatric vertigo cases may not be necessary unless indicated by clinical red flags such as focal neurological deficits or abnormal examination findings.

Similarly, EEG was performed in 34.9% (n=95) of patients, with epileptiform abnormalities detected in only 6.3% of cases. In the study by Batu et al.⁵, EEG was performed in 83 out of 100 pediatric patients presenting with vertigo, and pathological findings were observed in 15 cases. This proportion was higher than generally reported in the literature and was attributed to the relatively high rate of EEG utilization in their cohort⁵. Our study aligns with existing literature, indicating that while epilepsy can present with vertigo as an ictal or peri-ictal manifestation, it is an uncommon etiology in pediatric populations and should be considered primarily when supported by clinical features such as altered awareness, stereotyped episodes, or abnormal neurological findings^{27, 28}. These findings support a more selective approach to ordering MRI and EEG in children with vertigo, focusing on clinical indicators rather than routine evaluation.

The age-based distribution of vertigo-related diagnoses observed in our study aligns with previous literature that highlights developmental differences in etiology. BPVC and epilepsy were more common in younger children, while psychogenic vertigo and orthostatic hypotension were more common among adolescents. This pattern is consistent with the findings of Yücel²⁷, who reported a predominance of BPVC and epileptic vertigo in early childhood and psychogenic etiologies in the adolescent group. The higher frequency of orthostatic hypotension in adolescents (31.6%, n=54 vs. 9.2%, n=9) may be explained by increased orthostatic stress and hormonal changes during puberty, which have been shown to influence autonomic regulation²⁹.

Although psychogenic vertigo was more common in adolescents, the difference did not reach statistical significance. However, the trend reflects broader observations that psychological stress, somatization, and school-related anxiety become increasingly prominent with age and may manifest as dizziness or balance complaints³⁰. In contrast, the significantly higher prevalence of BPVC and epilepsy in children under 12 years supports the theory that immature vestibular pathways and age-specific paroxysmal disorders contribute more prominently to vertigo in younger children^{3, 22}. These findings emphasize the importance of age-specific diagnostic considerations in the evaluation of pediatric vertigo. Although these age-related diagnostic patterns are consistent with existing knowledge, the present study, conducted in a large pediatric neurology cohort, reinforces these associations and provides real-world evidence to support the integration of developmental factors into diagnostic algorithms.

In our study, 13.6% (n=37) of the patients remained without a definitive etiology for vertigo despite thorough clinical and diagnostic evaluation. This proportion is comparable to previous studies; for instance, Božanić Urbančič et al.³¹ reported that the etiology of vertigo could not be determined in 112 out of 257 children (43.6%) in their study. Similarly, Davitt et al.³² found an unknown cause in 11.7% of 2,726 pediatric patients evaluated for dizziness and vertigo, which aligns closely with our findings. This highlights the importance of further investigations and multidisciplinary support for unclear cases.

For further evaluation, ENT consultations were performed in 56 patients (20.6%), cardiology consultations in 38 (14.0%), and ophthalmology consultations in 12 (4.4%). Similarly, Božanić Urbančič et al.³¹ reported cardiology and ophthalmology consultations in 28% and 32.6% of cases, respectively, reflecting the importance of a broad diagnostic approach²⁸. In the study by Anoh-Tanon et al.³³, ophthalmology consultations were performed in 5.2% of pediatric patients with vertigo, and symptoms improved in two-thirds of these cases following simple ophthalmological interventions. Similarly, in our cohort, 5 out of 12 patients who received ophthalmologic consultation showed clinical improvement with targeted treatment³³. These results emphasize the importance of routine visual assessment in children with vertigo, as even in cases with an established etiology, unrecognized ophthalmologic problems may exacerbate vestibular symptoms and delay recovery²².

The distribution of symptoms across diagnostic categories in our study underscores the value of symptom-based pattern recognition in pediatric vertigo. Headache and tinnitus were particularly frequent among patients diagnosed with vestibular migraine, aligning with prior studies that emphasize these features as key diagnostic clues in migraine-related vertigo⁵. On the other hand, syncope and visual blackouts were more common in patients with orthostatic hypotension, consistent with known autonomic dysregulation mechanisms in this group²⁸. The prevalence of nausea and vomiting across various etiologies, as shown in Figure 1, highlights their non-specific yet supportive role in clinical assessment. These findings suggest that although some symptoms are shared among conditions, others may provide diagnostic direction and help guide a more focused evaluation.

Study Limitations

This study has several diagnostic limitations that should be considered when interpreting the findings. First, pediatric patients with vertigo often present to general pediatricians, and only selected cases are referred to pediatric neurology, which may lead to underrepresentation of otologic etiologies. Second, diagnoses, such as epilepsy, were based primarily on clinical history and routine EEG recordings, without video-EEG monitoring during attacks. Third, although metabolic factors such as anemia and vitamin B12 deficiency were associated with vertigo on the basis of symptomatic improvement, a causal relationship could not be objectively confirmed. Finally, due to the retrospective design, the exact duration of individual vertigo episodes (ictal duration) was not consistently documented, preventing subgroup analyses based on attack duration. In addition, due to the retrospective design and reliance on routinely collected electronic medical records, excluded patients could not consistently be assigned to a single primary exclusion category; therefore, exclusion reasons are reported descriptively rather than as detailed numerical subgroups.

CONCLUSION

This study provides a detailed overview of pediatric vertigo, emphasizing that most cases are benign and clinically identifiable, with age-dependent etiological trends. MRI and EEG should be reserved for cases with a strong clinical suspicion. The recognition of reversible metabolic conditions, such as vitamin B12 deficiency, and the inclusion of multidisciplinary assessments involving ENT, cardiology, and ophthalmology are essential for accurate diagnosis and effective management.

Ethics

Ethics Committee Approval: The study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Ethical approval for this study was obtained from the Ethics Committee of Medipol University (Non-Interventional Clinical Research Ethics Committee on with decision number: 464, date: 17.04. 2025.

Informed Consent: This is a retrospective study.