A Practical Diagnostic Approach to Pediatric Episodic Vestibular Syndrome

Pediatric episodic vestibular syndrome (pEVS) is a frequent source of diagnostic uncertainty because recurrent vertigo, dizziness, and unsteadiness in children may arise from disorders with markedly different mechanisms, prognostic implications, and management pathways. Symptom descriptions are often imprecise, interictal examination may be normal, and similar recurrent attack patterns may reflect spontaneous, triggered, neurologic, autonomic, audiovestibular, or extravestibular conditions. This Perspective proposes a clinician-oriented, phenotype-first framework for the practical evaluation of pEVS, grounded in the International Classification of Vestibular Disorders and Bárány Society consensus criteria where available. The proposed approach begins with structured history taking and focused bedside examination, emphasizing the core symptom category, attack duration, trigger profile, and associated migraine, auditory, autonomic, and neurologic features. Recurrent attacks are then organized into clinically recognizable phenotypes, including spontaneous non-migraine and migraine-related presentations, auditory phenotypes, ultrabrief stereotyped attacks, trigger-related attacks, orthostatic/autonomic phenotypes, motion- or visually-triggered dizziness, episodic vertigo with transient neurologic signs, and anxiety-related presentations. Rather than providing an exhaustive etiologic review, this framework is intended to support bedside classification, guide selective ancillary testing, and facilitate longitudinal reassessment, as diagnostic reclassification may occur over time. A phenotype-driven approach may improve diagnostic reasoning, support more rational use of ancillary testing, and facilitate earlier recognition of both common and less frequent but clinically important disorders.