RESEARCH ARTICLE

Period Prevalence of Dizziness and Vertigo in

Adolescents
Thyra Langhagen1,2*, Lucia Albers3, Florian Heinen1,2, Andreas Straube2,4,
Filipp Filippopulos2,4, Mirjam N. Landgraf1,2, Lucia Gerstl1,2, Klaus Jahn2,4,5, Rdiger von
Kries3
1 Department of Paediatric Neurology and Developmental Medicine, Hauner Childrens Hospital, Ludwig-
Maximilians-University, Munich, Germany, 2 German Center for Vertigo and Balance Disorders, Ludwig-
Maximilians-University, Munich, Germany, 3 Institut of Social Paediatrics and Adolescents Medicine,
Division of Epidemiology, Ludwig-Maximilians-University, Munich, Germany, 4 Department of Neurology,
Ludwig-Maximilians-University, Munich, Germany, 5 Schn Klinik Bad Aibling, Bad Aibling, Germany

These authors contributed equally to this work.

* Thyra.Langhagen@med.uni-muenchen.de

Abstract

Objectives
OPEN ACCESS
To assess the period prevalence and severity of dizziness and vertigo in adolescents.
Citation: Langhagen T, Albers L, Heinen F, Straube
A, Filippopulos F, Landgraf MN, et al. (2015) Period
Prevalence of Dizziness and Vertigo in Adolescents. Methods
PLoS ONE 10(9): e0136512. doi:10.1371/journal.
In 1661 students in 8th-10th grade in twelve grammar schools in Munich, Germany informa-
pone.0136512
tion on vertigo/dizziness was assessed by a questionnaire in the class room setting. Three
Editor: Zoi Kapoula, UMR8194, FRANCE
month prevalence of dizziness/vertigo was estimated; symptoms were categorized as
Received: May 27, 2015 orthostatic dizziness, spinning vertigo, swaying vertigo or unspecified dizziness. Duration of
Accepted: August 4, 2015 symptoms and impact on daily life activities were assessed.
Published: September 11, 2015
Results
Copyright: 2015 Langhagen et al. This is an open
access article distributed under the terms of the 72.0% (95%-CI = [69.874.2]; N = 1196) of the students (mean age 14.51.1) reported to suf-
Creative Commons Attribution License, which permits fer from at least one episode of dizziness or vertigo in the last three months. Most adolescents
unrestricted use, distribution, and reproduction in any
ticked to have symptoms of orthostatic dizziness (52.0%, 95%-CI = [49.554.4], N = 863).
medium, provided the original author and source are
credited. The period prevalence for the other types of vertigo were spinning vertigo: 11.6%, 95%-CI =
[10.113.3], N = 193; swaying vertigo: 12.2%, 95%-CI = [10.613.8], N = 202; and unspeci-
Data Availability Statement: All relevant data are
within the paper and its Supporting Information file. fied dizziness: 15.2%, 95%-CI = [13.517.1], N = 253. About 50% of students with spinning
vertigo and swaying vertigo also report to have orthostatic dizziness. Most vertigo/dizziness
Funding: The study was supported by an
unrestricted fund of the DMKG (German Headache types were confined to less than one minute on average. The proportion of students with any
Society) and by the German Federal Ministry of dizziness/vertigo accounting for failure attending school, leisure activities or obliging them to
Education and Research (Grant code 01 EO1401). stay in bed were more pronounced for spinning or swaying vertigo.
The funders had no role in study design, data
collection and analysis, decision to publish, or
preparation of the manuscript. Conclusion
Competing Interests: The authors have declared Dizziness and vertigo in grammar school students appear to be as common as in adults. In
that no competing interests exist. face of the high period prevalence and clinical relevance of dizziness/vertigo in adolescents

PLOS ONE | DOI:10.1371/journal.pone.0136512 September 11, 2015 1/9

 Period Prevalence of Dizziness and Vertigo in Adolescents

there is a need for prevention strategies. Risk factors for dizziness/vertigo need to be
assessed to allow for conception of an intervention programme.

Introduction
Dizziness and vertigo are common causes of medical consultation in general [1,2]. In adults
the life time prevalence of any dizziness type is estimated in 23.2% [3] and the lifetime preva-
lence of vestibular vertigo bad enough to interfere with activities in 29.5% [1]. The one month
prevalence of dizziness varies from 15.8% [4] to 23% [5], and for dizziness severe enough to
interfere with normal activities a 10.9% one month prevalence was described [5]. The reported
one year prevalence of vertigo was 59.2% for adults [6]. In contrast to adults, epidemiologic
data on dizziness and vertigo in children and adolescents are sparse. There are only three popu-
lation based studies for the age ranges between one and 15 years [79] reporting prevalence
estimates of dizziness and vertigo: In children aged five to 15 years the one year period preva-
lence of at least one episode of vertigo or dizziness was 18% and the prevalence for at least
three episodes was 5.3% [7]. In another paper the lifetime prevalence of vertigo and dizziness
in children aged 1 to 15 years was estimated as 8% [8]. Another study in 10 year old children
reported a prevalence of 5.7% [9]. In the first two studies, the wide age range covered is a limi-
tation. The third study mentioned, focused on a particular age, so results cannot be generalized.
We are not aware of any data on the period prevalence of dizziness and vertigo for adolescents.
So far assignment to vertigo types cannot be based on an established classification system.
Recently, the Brny Society has launched an effort for a consented classification system [10].
However, until now there is no validate vertigo questionnaires for children and adolescents
available.
In this study we assessed the period prevalence of vertigo and dizziness in a large sample of
grammar school students (mean age 14.5 1.1). In order to assess the clinical relevance of diz-
ziness and vertigo in these adolescents we also asked for the frequency and duration of the
symptoms and their impact on restriction of social activities and school attendance.

Methods
Population
The target population for this cross sectional study was grammar school students (aged 12 to
19 years) in Munich. All public grammar schools (academically oriented secondary schools) in
the Munich area were invited and principals of 12 out of 47 eligible grammar schools agreed to
participate in this study. The reasons for declining participation were its related administrative
work load and inability to organize the study in the school setting due to lack of staff. Partici-
pants were restricted to students of the 8th, 9th and 10th grade. Beyond questions on dizziness
and vertigo headache and risk factors of headache were assessed. For the latter condition this
cross sectional approach was also used for a cluster-randomized trial [11]. The study was con-
ducted between November 2011 and January 2012. Students with full information about dizzi-
ness and vertigo were included for this analysis. The questionnaires were answered during a
school lesson and a member of the author team was present to clarify questions.
The study was approved by the Data Safety Officer and the Ethics Committee of the Medical
Faculty of the Ludwig-Maximilians-University Munich and the Bavarian Ministry for Teaching
and Culture. All parents/guardians and students (> 14 years of age) gave written informed
consent to participate in the study.

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 Period Prevalence of Dizziness and Vertigo in Adolescents

Assessment of dizziness and vertigo, vertigo types, duration, frequency

and constraints in social activities caused by dizziness or vertigo
Period prevalence of dizziness/vertigo was assessed by the question Did you suffer from dizzi-
ness or vertigo during the last 3 month? which could be answered withyes or no. If stu-
dents ticked yes they were asked to further specify the vertigo type: spinning vertigo like in a
carrousel (spinning vertigo), swaying vertigo like on a small boat (swaying vertigo), feeling
of impending black out when rapidly standing up (orthostatic dizziness), or neither of the
three types (unspecified dizziness).
For the duration of dizziness/vertigo the following time intervals could be ticked: up to one
minute, one minute to 30 minutes, 30 minutes to four hours, four hours to 24 hours,
one to seven days, more than seven days. In this analysis the last three categories were com-
bined to more than four hours.
Students who reported to have experienced dizziness/vertigo in the preceding three months
were asked for the frequency of vertigo/dizziness in the last 12 months. The frequencies
once, less than five times or more than five times could be ticked.
Constraints in social activities caused by dizziness/vertigo were assessed by the questions
Did the dizziness/vertigo cause considerable constraints in social activities? Did you have to
refrain from . . . 1) . . . attending school because of the dizziness/vertigo?, 2) . . .doing lei-
sure activities because of the dizziness/vertigo?, 3) Or did you have to stay in bed because of
the dizziness/vertigo? which all could be answered with yes or no.

Statistical methods
Period prevalence for dizziness or vertigo and vertigo types with 95% confidence intervals (CI)
were calculated. For the vertigo types a distinction between occurrence of only one type or
combination with one, two or three other vertigo-symptoms was made. Furthermore a cross
tabulation showing the co-occurrence with other vertigo types was calculated.
For the frequency, duration and constraints in social activities caused by dizziness or vertigo
absolute numbers and prevalence with binomial 95%-CI for the four vertigo types were
calculated.

Results
Participation rate was 73.5% (assessed in a random sample of six schools). In total 1661 of the
1674 student participating in this study (mean age 14.5 1.1) of the 8th, 9th and 10th grade filled
in the questionnaire and gave full information on dizziness/vertigo (<1% drop outs because of
incomplete information).
72.0% (95%-CI = [69.874.2]) of the students reported to suffer from at least one episode of
dizziness or vertigo in the last three month. Most adolescents ticked to have symptoms of
orthostatic dizziness (52.0%, 95%-CI = [49.554.4]). The period prevalence for the other types
of vertigo were between 1015% (spinning vertigo: 11.6%, 95%-CI = [10.113.3]; swaying ver-
tigo: 12.2%, 95%-CI = [10.613.8], unspecified dizziness: 15.2%, 95%-CI = [13.517.1]. Ortho-
static dizziness was more common in girls (58.6%, 95%-CI = [53.361.9]) than in boys (44.0%,
95%-CI = [40.447.7]; similarly swaying vertigo (girls: 15.0%, 95%-CI = [12.817.5]; boys:
8.6%, 95%-CI = [6.710.8]) and unspecified dizziness (girls: 17.1%, 95%-CI = [15.320.4];
boys: 12.3%, 95%-CI = [10.114.9]) whereas there was no significant difference in spinning
vertigo (girls: 12.4%, 95%-CI = [10.314.7]; boys: 10.7%, 95%-CI = [8.613.2]).
Most students ticked more than one type of vertigo as illustrated in Fig 1. More than half of
the adolescents with spinning vertigo and swaying vertigo report to have a combination of

PLOS ONE | DOI:10.1371/journal.pone.0136512 September 11, 2015 3/9

 Period Prevalence of Dizziness and Vertigo in Adolescents

Fig 1. Three-month prevalence vertigo types.

doi:10.1371/journal.pone.0136512.g001

vertigo symptoms. Two thirds of the adolescents reporting orthostatic dizziness respectively
unspecified dizziness did not report any other vertigo/dizziness type.
In Table 1 vertigo types are cross tabulated one by one. About 50% of students with either
spinning vertigo or swaying vertigo also report to have orthostatic dizziness whereas co-occur-
rence of spinning and swaying vertigo was only observed in 25.9% of adolescents.
Most vertigo/dizziness types were confined to less than one minute on average (Fig 2). Consid-
erable differences with respect to duration between the vertigo types were observed: adolescents
with orthostatic dizziness reported shorter duration of less than one minute (64.2%, 95%-CI =
[60.967.4]) compared to spinning (39.7%, 95%-CI = [32.747.0]) and swaying vertigo (40.2%,
95%-CI = [33.347.4]), whereas for spinning vertigo and swaying vertigo also durations of 30
minutes up to more than 7 days were reported (spinning vertigo: 17.5%, 95%-CI = [12.323.6];
swaying vertigo: 15.6%, 95%-CI = [10.821.4]) compared to orthostatic dizziness (6.2%, 95%-CI =
[4.67.9]) and unspecified dizziness (10.8%, 95%-CI = [7.215.3]).

Table 1. Combination of vertigo types.

Orthostatic dizziness Spinning vertigo Swaying vertigo Unspecied dizziness

% (N)
Orthostatic dizziness N = 863 100 (863) 11.47 (99) 11.01 (95) 10.08 (87)
Spinning vertigo N = 193 51.30 (99) 100 (193) 25.91 (50) 12.44 (24)
Swaying vertigo N = 202 47.03 (95) 24.75 (50) 100 (202) 10.89 (22)
Unspecied dizziness N = 253 34.39 (87) 9.49 (24) 8.70 (22) 100 (253)
doi:10.1371/journal.pone.0136512.t001

PLOS ONE | DOI:10.1371/journal.pone.0136512 September 11, 2015 4/9

 Period Prevalence of Dizziness and Vertigo in Adolescents

Fig 2. Duration of vertigo types.

doi:10.1371/journal.pone.0136512.g002

However frequency of dizziness/vertigo does not differ between the vertigo types (Fig 3).
Consistently high frequencies of more than five times were reported by about 50% of the stu-
dents for every vertigo type except unspecified dizziness.
The proportion of students in whom dizziness/vertigo accounted for failure in attending
school or doing leisure activities or obliging them to stay in bed is shown in Table 2. These con-
straints were more pronounced for spinning vertigo and swaying vertigo. Significant differ-
ences compared to orthostatic dizziness were seen for these constraints of not doing leisure
activities and not being able of getting up from bed.

Fig 3. Frequency of vertigo types in the last 12 months.

doi:10.1371/journal.pone.0136512.g003

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 Period Prevalence of Dizziness and Vertigo in Adolescents

Table 2. Constraints in social activities caused by dizziness or vertigo.

Not attending school Not doing leisure activities Not being able to get up

%95%-CI(N)
Orthostatic dizziness 9.22[07.3511.39](77) 18.50[15.9221.29](115) 19.90[17.2522.77](167)
Spinning vertigo 14.36[09.6020.34](26) 32.24[25.5339.53](59) 29.73[23.2536.88](55)
Swaying vertigo 15.98[11.1221.91](31) 37.19[30.4644.30](74) 28.93[22.7135.81](57)
Unspecied dizziness 9.20[05.9213.48](23) 19.52[14.8124.97](49) 24.19[19.0030.02](60)
doi:10.1371/journal.pone.0136512.t002

Discussion
Dizziness and vertigo are common symptoms in adolescents: 72% of adolescents had at least
one dizziness/vertigo episode in the last three months. Symptoms described as dizziness are by
far more common than those described as vertigo. Attacks of swaying or spinning vertigo are
often of higher clinical relevance because of longer duration and impact on social activities
compared to attacks of dizziness. In 30% of the cases dizziness and vertigo occurred in the
same subject. It is impossible, however, to determine which symptom precedes the other or
might be causal.
The high three month period prevalence of orthostatic dizziness, accounting for most of the
cases of dizziness/vertigo, contrasts with a much lower prevalence in a population-based study
in adults in Germany [12]. In this telephone survey the 12 month prevalence for orthostatic
dizziness was 11%. However, the participants were asked for the occurrence of moderate or
severe orthostatic dizziness only, whereas we asked in our paper and pencil questionnaire for
any orthostatic dizziness regardless the severity. Since orthostatic dizziness had in general only
limited impact on social activities in our study, it may be assumed that most students in our
study had only mild dizziness. Additionally classification of orthostatic dizziness and vestibular
vertigo had to be mutually exclusive in the adult study [12] whereas in our study there was a
considerable co-existence between orthostatic dizziness and vertigo. The patient group with
combined symptoms of vertigo and dizziness might be substantial, since several vestibular dis-
orders (vestibular migraine, M. Mnire's and benign paroxysmal positional vertigo) are fre-
quently associated with migraine [1315], and migraine is associated with orthostatic dizziness
and syncope [16]. As in adult studies, orthostatic dizziness was more common in girls than in
boys [12] and female sex has been identified as an independent risk factor for orthostatic dizzi-
ness [17]. The overall prevalence of vertigospinning and swaying vertigo in isolation or both
combinedwas 20.8% in our study and in the same range as in most studies in adults [16].
The lower prevalence in the Neuhauser study [1] is likely to be a reflection of confinement to
moderate and severe symptoms and exclusion of combined symptoms. The prevalence esti-
mates in our study are higher than in previous studies in children [79] suggesting that the
prevalence in adolescents is more similar to the prevalence in adults [16]. This is an important
finding since there are no other studies addressing the prevalence of vertigo/dizziness in ado-
lescents specifically.
An interesting finding is the co-occurrence of different types of vertigo, which has been also
noticed by Humphriss et al., who found 26.8% of the children (all aged 10 years) reporting at
least 3 different descriptions of their dizziness [9]. Dizziness, swaying and spinning vertigo
have been reported to be associated with migraine [13,15]. The diagnostic entity of vestibular
migraine [18] has reached international acceptance. There are other clusters of vertigo/dizzi-
ness symptoms such as the association of vestibular vertigo syndromes and vestibular migraine
to somatoform dizziness/vertigo [19,20]. Co-occurrence of these symptoms may reflect the

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 Period Prevalence of Dizziness and Vertigo in Adolescents

described co-occurrence of different vertigo syndromes. An alternative explanation might be

the subjective nature of the clinical symptoms, which is difficult to assign to a specific category.
Therefore students might have ticked a combination of different descriptions.
Another important finding is the high impact of vertigo symptoms on restriction of social
activities pointing to the high clinical relevance of vertigo. Similarly in the survey of Neuhauser
et al. [21], which only ascertained moderate and severe vertigo, the reported dizziness/vertigo
was severely impairing in almost two-thirds of cases, leading to sick leave, medical consultation
or interruption of daily activities. Niemensivu reported vertigo severe enough to stop the pres-
ent activity in 69% of affected children aged 5 to 15 years [8]. Applying the same case definition
Humphriss and Hall found that 51.5% of the 10 year old children suffering from vertigo had to
stop their present activity [9]. In our study a more explicit definition of interference in chosen:
we assessed inability to go to school, participate in leisure activities or even were forced to lie
down. Surprisingly even 10% of students with orthostatic dizzinesswhich could be assumed
as less impairingreported to not attend school because of their dizziness. A possible explana-
tion for this could be the coexistence with other types of vertigo. However, nearly half of those
students who reported not attending school suffered from isolated orthostatic dizziness.
Unspecified dizziness, which can also include non-organic vertigo or dizziness, was observed
in only 8% of those students.
The strength of the study is the focus on adolescents, an age group previously insufficiently
investigated. Most students (98%) participating in this study are in the age range of 13 to 17
years. To our knowledge this is the first study ascertaining the period prevalence of vertigo in
an adolescent population of up to 19 years and examining its clinical characteristics and its
consequences on daily and school activities.
One limitation of the study is the restriction of the study population to students from gram-
mar schoolsabout 50% of the birth cohort [22]which may limit external validity: children
in grammar schools are more likely to come from socially advantaged families with higher
income. Whether this results in an over-estimate of prevalence (e.g. from over-attentive
parents or more articulate parents/children) or underestimates the prevalence of vertigo/dizzi-
ness in the general population (e.g. if vertigo/dizziness is socially patterned like other health
outcomes and a higher socioeconomic status would be associated with better health states)
remains unclear.
Furthermore, all results are based on self-administered questionnaire by the students which
has to be considered in the comparison to other studies.
Participation rate was 73.5%. The 26.6% of the student not participating in our study could
be explained by 1) students/parents gave no consent to participate or 2) students did not attend
class on that day. However, selection bias due to these reasons is rather unlikely: 1) It may be
possible that children/parents were more likely to consent if they had a problem with head-
aches, which might have resulted in a higher estimate of prevalence if dizziness is associated
with headache (as it is in migraine). However, headache prevalence in this study sample (84%)
is comparable to many other studies in this age group [11]. 2) Possible students did not attend
class because they had headache or vertigo resulting in an underestimation of vertigo. This is
very unlikely as we found a very high vertigo prevalence.
A limitation of all studies on vertigo/dizziness is the lack of an established international clas-
sification for dizziness/vertigo as it is available for other subjective complaints such as headache
(for example the ICHD for headache [23]). Recently, the Brny Society has launched an effort
for a consented classification system [10]. So far assignment to vertigo types cannot be based
on an established classification system making it difficult to validate vertigo questionnaires for
children and adolescents. Since neither the German nor the English language differentiate very
clearly between dizziness and vertigo we presented our questions on dizziness/vertigo in a

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 Period Prevalence of Dizziness and Vertigo in Adolescents

simple and coherent way with examples for the respective vertigo types. The "vocabulary" prob-
lem could also be a probable contributor to the many instances of "double-ticking" for different
types of vertigo.
Furthermore vertigo type specific prevalence estimates show large confidence intervals
showing imprecision, which is a reflection of the small sample of students with spinning, sway-
ing vertigo. Despite the small sample sizes and possible uncertainties as how to label the vertigo
types, however, significant differences between dizziness and both spinning and swaying ver-
tigo are observed.

Conclusion
Period prevalence dizziness and vertigo in grammar school students has already reached adult
levels. Although we could not assess whether this also pertains to adolescents in other school
types, this high period prevalence and clinical relevance of dizziness/vertigo points to a need
for prevention strategies.

Supporting Information
S1 Dataset.
(CSV)

Acknowledgments
We thank the participating students and teachers, and the medical colleges who assessed the
students responding the questionnaires at their schools. Furthermore we would like to thank
the DMKG (German Headache Society) and German Federal Ministry of Education and
Research (BMBF) for giving us the opportunity to perform this study.

Author Contributions
Conceived and designed the experiments: FH AS FF ML RK KJ. Performed the experiments:
TL FF ML. Analyzed the data: LA RK. Contributed reagents/materials/analysis tools: TL LG
KJ. Wrote the paper: TL LA FH AS FF ML LG KJ RK.

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