Instrumental Assessment and Pharmacological Treatment of Migraine-Related Vertigo in Pediatric Age

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, 

Compliments to your work – literature review and presentation of the news on the field.

I would agree that classification, diagnosis and treatment of pediatric vestibular problems is demanding, but any new classification must be accepted from all specialists, dealing with this problem. Pediatric neurologists also have to accept new classification.

Please add or change as sugested:

 1.      In chapter 3.1. I think these papers should be discussed and listed in literature.

 Timothy Yates, Benign paroxysmal torticollis Handb Clin Neurol. 2023:198:241-247.doi: 10.1016/B978-0-12-823356-6.00013-5.  PMID: 38043967 DOI: 10.1016/B978-0-12-823356-6.00013-5

 Indicators of pediatric peripheral vestibular disorder: A retrospective study in a tertiary referral center.

Božanić Urbančič N, Vozel D, Kordiš Š, Hribar M, Urbančič J, Battelino S. Int J Pediatr Otorhinolaryngol. 2022 Aug;159:111221. doi: 10.1016/j.ijporl.2022.111221

 2.      Line 146 – vestibular system is not definitive developed at birth. It is developing until end of puberty. Please change and add literature.

 3.      Line 218: What do you mean by »CT is reliable from after 6-12 months«? Even in newborn babies can be performed if you use 1000 ml 15 degree Celsius water – but it is very stressful for babies and examiners. Please reconsider.

 4.      Line 253 and 254 – there must be a citation for such statement.

 5.      In conclusion – the sentence: »Now the news in diagnosis and treatment of…. are….«, is missing, as you promised in your tittle.

 

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

I read the overview article of my respected colleagues a week ago, so I had enough time to think about everything written. Children's dizziness is generally an intriguing and not too elaborate topic, so every new text has a certain weight and significance.
Why aren't there too many works dealing with this topic? Well, first of all, balance disorders in children are mostly harmless and stop spontaneously without the need for any significant intervention, which does not mean that there aren't more serious and even severe cases, but they are really rare. Some authors believe that vertigo in childhood is not such a serious disease, because the symptoms of the disease are much less pronounced than in adults, and the posturographic findings between attacks are almost normal!! (Riina N, 2005; Erbek SH, 2006)
Knowledge about this topic is needed above all to calm the usually very worried parents, while the children themselves are usually not even aware that something unusual is happening to them.
Although most diseases that cause vertigo in adulthood also occur in childhood, the frequency of individual causes is quite different in the child and adult populations.
The connection between migraines and children's vertigo has been known for a long time (Fenichel, 1967), and various statistics show their different share among all causes of vertigo in children, which ranges up to 40%. however, it should be said that all the listed results of various statistics are acceptable, but with a note that they depend very much on the locality, the time when they are recorded and the population that gravitates to a certain institution and clinic. I would exclude the results in which we have a very high proportion of sinusitis (Zhang et al. 2023) from the text, because such a result, precisely for the stated reasons, stands out from the vast majority of others. Our statistics on children's vertigo are almost identical to those from Munich (Jahn K 2011), and we are talking about neuropediatrics, while we are a small ENT polyclinic, which, admittedly, has become a reference centre for vertigo in the country and somewhat wider. Here, we have a higher proportion of orthostatic vertigo than others, but everything else is mostly similar.
I would like to praise the authors who draw attention to the very common occurrence of vertigo after CI, which is a generally quite unknown fact. Also, it is very significant and desirable to be reminded of the new terminology introduced by van de Berg in 2021, introducing the new term RVC instead of the previously used BPVC, which together with VMC forms a common syndrome of vestibular migraine in childhood.
Laboratory diagnostics for children is the same as for adults, only adapted to their age. The problem is that most of the diagnostic systems developed to date are not adapted to children, so the diagnosis of children's vertigo is still based mainly on a careful and detailed history and clinical findings.
When it comes to Laboratory diagnostics, my opinion is that the dates when certain tests can be done are a little premature, but this can also depend on the population and the suitability of the equipment.
Perhaps other manifestations of migraine in children should be mentioned, such as colic cyclic vomiting, torticollis and acephalgic migraine, and acute confused migraine... Because this is also generally little known, most doctors still perceive migraine exclusively as a headache.
It is necessary to indicate which children need to be processed in the laboratory, namely: Children with a temporary hearing lesion, Children with various forms of vertigo, Children with coordination disorders or delayed development (due to recurring or chronic ear infections), Children with learning difficulties (due to disorders in the vestibular system)
Treatment: Most vestibular syndromes in children have a good prognosis and can be treated very successfully. While avoiding unnecessary tests, it is very important to arrive at a diagnosis quickly, apply adequate treatment and enable unimpeded psychomotor development.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

REVIEW OF ADVENCES IN DIAGNOSIS AND TTRETAMENT OF MIGRAINE-RELATED VERTIGO IN PEDIATRIC AGE

The authors review the most important papers that focus on the clinical characteristics of vestibular migraine (VN) in childhood.

The problem is actually of substantial importance, as VN is 0.7 t0 15 %, with a prevalence of 32.7%. One difficulty may lay on the fact that the manifestations may be different indifferent age groups, the patients cannot articulate their symptoms precisely and the manifestations involve an intense vasovagal reaction and behavioral manifestations of fear. Their review cite the 2021 Update on diagnostic criteria.

The methodology screened the usual database including PubMed, Embase and Cochrane libraries. The most important work form Van der Berg, et al, on behalf of the Bárany Society which includes Definite and Probable Migraine of Childhood and Recurrent Vertigo of Childhood.

Pertaining Recurrent Vertigo of Childhood (RVC): At least three episodes with vestibular symptoms of moderate to severe intensity lasting 1 I to 72 hours but lacking history of migraine with or without aura. In a study of 42 children, the attacks lasted 1 minute to 4 hours, symptoms/sigs included nausea, vomiting and fear. Of interest, attack duration and intensity was worse in female patients.

The diagnostic criteria remains a bit imprecise. In a retrospective study, among 1021 patients, 35 % had a diagnosis of VM. The vestibular function test recommend varied by age with vHIT and cVEMP’s prior to age 2, vHIT and evoked potentials from ages 3-7 and a complete battery after age 8. Caution in the interpretation of the test is recommended, due to different developmental milestones of the vestibular system. The technological challenges make the recording and interpretation difficult.

In terms of treatment, for prevention: tricyclics, cyproheptadine, topiramate, triptans and gabapentin have been utilized. In addition, vestibular suppressants can be used during the ictal events.

What we learn from this review is the need to acquire a better handle on the diagnosis, this reviewer is surprised that there are no articles included to address recording by parents of the “acute events” with cell phones or with devices that may record nystagmus with fixation block. This could offer a wealth of information when the attacks are brief.

Recommendations

1.      I believe that this is good work. Presenting tables here with enable a briefer text description and a more clear presentation of the data. One for probable and definite VM and one of RVC, and a second table on children age and possible vestibular function test, and preventive/ictal treatment.

2.      Please include papers with episodic ataxia 2 in childhood (this is often in the differential), the patient may have interictal nystagmus, and some have migraine as well!

3.      Any role for neuroimaging? Perhaps if nystagmus is present, particularly downbeat.

Author Response

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Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript, which presents a very important topic for pediatric otoneurology. My considerations about the study are described below.

 

Abstract:

 

- Well-written abstract, clearly outlining the content of the study.

 

Introduction:

 

- The second paragraph of the introduction is very long, I suggest dividing it into two paragraphs.

 

- In the introduction, the authors mention the cochlear implant, however, this device is only used by children with hearing loss who often present vestibular dysfunction and consequently vestibular symptoms. However, the authors mention cochlear implants in the introduction without mentioning children with hearing loss, who are cochlear implant users. I suggest including children with hearing loss in the text and mentioning that they have vestibular dysfunctions and symptoms.

 

- Objective: Adequate and equal to the abstract

 

Methods:

 

- What were the eligibility criteria (inclusion and exclusion) for the articles?

 

- What was the type of study of the articles that would be included?

 

Results:

 

- Authors must adapt the reference from van de Berg et al to van de Berg et al [12].

 

- The division of results by topic made the study clearer and more direct in terms of evidence so that readers can easily find what they want to read in the article.

 

 

Discussion:

 

- Concise, yet targeted and precise.

 

Conclusion:

 

- The conclusion must be rewritten. The conclusion brings concepts and is not appropriate. Authors must remember that the conclusion of the study responds to the objectives of the study. Thus, in the conclusion session, authors must directly conclude what they found and respond to the objective of the study. I suggest that the authors rewrite the conclusion, making it more focused on the objective of this study.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

The authors addressed all the issues raised in the previous review. They added tables which I believe are well designed and helpful.

Reviewer 4 Report

Comments and Suggestions for Authors

Congratulations to the authors, they did a good job.