Vertigo and Dizziness

Vertigo and Dizziness

1 Overview

Summary and Quick Facts

  • Vertigo is an unpleasant sensation of spinning or dizziness that can be quite debilitating. It’s more common in older adults and typically arises from problems in the inner ear structures.
  • This protocol summarizes the causes of vertigo and the different treatment strategies available, including an innovative technique to reposition inner-ear structures at home.
  • Many cases of vertigo may be relieved by one or more of the strategies outlined in this protocol. You’ll also learn about some lesser-known causes of vertigo, which can be discussed with a doctor, if vertigo remains unexplained.
  • People are often familiar with Ginkgo biloba extract because of its renowned brain health benefits. However, clinical trials have shown that ginkgo may be effective for vertigo, as well.

Vertigo, typically characterized by a sensation of spinning, is usually caused by problems involving the inner ear (peripheral vertigo) or central nervous system (central vertigo). Seeking medical attention quickly for sudden unexplained vertigo is essential, as stroke may be an underlying cause in some cases.

Dizziness usually falls into one of four categories: vertigo, fainting sensation, imbalance sensation, and lightheadedness.

Evidence indicates some types of vertigo and dizziness are associated with abnormal glucose metabolism, osteoporosis, and sleep apnea.

Natural interventions, such as vitamin D, Ginkgo biloba, gastrodin, and coenzyme Q10 (CoQ10) have shown promise for the management of vertigo.

Causes and Risk Factors

  • The most common cause of vertigo is benign paroxysmal positional vertigo, which may account for up to 33% of cases. Another common cause of vertigo is Ménière’s disease.
  • Migraine sufferers are at a higher risk of developing vertigo, as are older people, females, and those with a family history.
  • Many medications can cause dizziness, including some antibiotics, statins, and antidepressants.

Diagnosis

  • Physicians must systematically exclude diagnostic possibilities in patients with dizziness. Ruling out urgent causes of vertigo and dizziness, such as stroke, is vital.
  • Nystagmus or other eye movement abnormalities may help a clinician rule out certain causes of dizziness.
  • A specialized maneuver called the Dix-­Hallpike test may help diagnose positional vertigo.

Treatment

  • Semont and Epley maneuvers, designed to move debris out of the semicircular canals in the inner ear, are effective in the majority of cases of positional vertigo.
  • Diuretic medications are commonly used to treat Ménière’s disease, but some evidence suggests medication may not be effective.
  • Medications such as antihistamines, antiemetics, anticholinergics, and benzodiazepines may be used during repositioning maneuvers or to temporarily relieve symptoms of severe positional vertigo, but these drugs do not treat the underlying cause of positional vertigo.

Novel and Emerging Strategies

  • In case reports, jugular vein abnormalities were corrected, resulting in a complete resolution of vertigo symptoms.
  • Flunarizine, a drug not approved for use in the United States, is an effective adjunct treatment for migraine-associated vertigo.
  • Emerging findings suggest serum protein S100-beta, a novel diagnostic biomarker, may someday be used to differentiate vertigo caused by vascular stroke.
  • The half somersault maneuver to move crystals out of the semicircular canals is a novel technique developed for at-home use without assistance. Compared with the Epley maneuver, those who used the half somersault experienced less dizziness and other complications and were more likely to remain in remission.

Diet and Lifestyle Considerations

  • Follow a consistent low-sodium diet for Ménière’s disease.
  • Avoid migraine trigger foods (including red wine, cheese, and chocolate).
  • Stress reduction, manual therapy, and acupuncture may be helpful.

Integrative Interventions

  • Vitamin D: Studies have shown vitamin D supplementation can improve positional vertigo, especially in those with low vitamin D status.
  • Ginkgo biloba: In a 12-week trial in subjects with vertigo, ginkgo extract daily was more effective and better tolerated than betahistine, a medication sometimes used to treat vertigo.
  • Gastrodin: A rigorous analysis of controlled clinical trials that used injections of gastrodin, an extract from the gastrodia plant, to treat vertigo concluded that this treatment was more effective than medication.
  • Coenzyme Q10 (CoQ10): Patients with congestive heart failure were treated with CoQ10 and 73% reported improvement in their vertigo.
  • Glutathione and related nutrients: A study in treatment-resistant patients with Ménière’s disease that included glutathione found that 21 of the 22 patients with vertigo reported complete recovery or substantial improvement 12 months after treatment. Based on these results, nutrient supplements that can increase glutathione levels, such as L-cysteine, vitamin C, whey protein, selenium, and N-acetylcysteine, may have a role in the treatment of vertigo and Ménière’s disease.

2 Introduction

Vertigo is characterized by a perception of motion while not moving, typically a sensation of spinning. Vertigo symptoms can be caused by a variety of different, underlying medical conditions. Vertigo is typically caused by problems involving the inner ear or the central nervous system (Wetmore 2013; AAFM 2005). Importantly, vertigo can be a symptom of a more serious condition, such as stroke. Seeking medical attention quickly for sudden unexplained vertigo is essential (Kerber 2009a).

About 30% of people older than 60 and half of people over 85 experience vertigo or dizziness (Fernandez 2015). Vertigo can interfere with the ability to work and live independently, which can reduce quality of life (Campellone 2013). Vertigo is also a common cause of falls among aging individuals, and falling is the leading cause of accidental death in seniors (Fernandez 2015; Holmes 2011; Agrawal 2013).

Although many people assume that “vertigo” and “dizziness” are synonyms, this is not the case. Vertigo typically includes a sensation of dizziness, but not all patients with dizziness also complain of a sensation of motion while not moving (vertigo). Conditions that can cause dizziness include pre-syncope, disequilibrium, and lightheadedness (Wipperman 2014; Susanto 2014; Post 2010; Samuels 2010).

Many cases of vertigo are attributable to problems related to the inner ear, and the pathobiology of these problems is largely understood, so the management approach is more straightforward (Wipperman 2014; Susanto 2014; Post 2010; Samuels 2010).

The most common type of vertigo, positional vertigo (also called benign paroxysmal positional vertigo), accounts for up to 33% of cases (Agrawal 2013). Positional vertigo is caused by displaced particles in the small canals of the inner ear. These canals are important parts of the body’s equilibration system. Positional vertigo can often be treated with maneuvers that move the particles out of the canals (Johns Hopkins Medicine 2016). However, most of these techniques must be executed by a clinician, which undermines their practical utility. But a novel repositioning technique called the half somersault maneuver can be performed at home and was shown in a randomized controlled trial to be better tolerated than other well-known techniques (Foster 2012; Span 2016).

Intriguing evidence indicates some types of vertigo and dizziness are associated with systemic conditions such as abnormal glucose metabolism (Kraft 1998; Kirtane 1984; D'Avila 2005; Mangabeira Albernaz 1984; Lehrer 1986; Serra 2009; Webster 2015), osteoporosis (Yu 2014), and sleep apnea (Sowerby 2010; Nakayama 2015; Kayabasi 2015; Gallina 2010), suggesting a comprehensive approach going beyond the inner ear and nervous system may be warranted. Moreover, several natural interventions, such as vitamin D, Ginkgo biloba, gastrodin, and coenzyme Q10, have shown promise for the management of vertigo (Buki 2013; Talaat, Kabel 2015). Other causes of vertigo, such as vestibular migraine and Ménière’s disease, may respond to medication (Johns Hopkins Medicine 2016).

In this protocol you will learn about several possible causes of vertigo and dizziness and how clinicians identify the cause in a given case. You will also discover a number of novel treatment strategies and several natural interventions that may help relieve vertigo and dizziness. Dietary and lifestyle considerations that may reduce the severity or frequency of vertigo attacks will be described as well.  

3 Background

Vertigo results from disturbances of the vestibular structures of the inner ear, which help control balance and orientation, or regions of the brain involved in balance control (Strupp 2013; NIH 2015; Wetmore 2013).

Positional vertigo, the most common type of vertigo, is caused by dislocation of particles from part of the inner ear called the otolith. Normally, these crystals help sense head movements. In positional vertigo, they move into another part of the inner ear called the semicircular canals, which contain sensors that help determine the head’s orientation relative to gravity. When the crystals from the otolith enter the semicircular canals and stimulate these sensors, a sensation of vertigo can arise (Mayo Clinic 2015).

There are two main types of vertigo: peripheral and central.

  • Peripheral vertigo arises from problems in the vestibular apparatus of the inner ear or the vestibular nerve. Vertigo as a side effect of medications is usually peripheral vertigo (NIH 2015).
  • Central vertigo arises from problems in the cerebellum or brainstem where postural information is processed.

Another type of vertigo, sometimes referred to as psychic or psychogenic vertigo, can be associated with anxiety, panic attacks, phobias, or other psychiatric disorders (Lin 2013; Chimirri 2013).

Table 1: Common Disorders That can Cause Vertigo (Wetmore 2013)

Disorder

Manifestations

Positional vertigo

Episodes of vertigo often lasting one minute or less and triggered by a specific movement of the head; Nystagmus (involuntary, rapid, sweeping movement of the eyes) is often present. Positional vertigo can have an intermittent course (Mayo Clinic 2015)

Vestibular migraine

Migraine-associated vertigo; wide variety of symptomatic presentations that can last from minutes to days. Typically associated with migraines, but headache and migraine symptoms are absent in up to 30% of cases (Strupp 2013; Espinosa-Sanchez 2015)

Ménière’s disease

Sudden onset vertigo lasting from one to 24 hours, often preceded by tinnitus (ringing in the ear), ear pressure or fullness on one side, and hearing loss. Visual disturbances, nausea, and vomiting are often present (Demetroulakos 2010)

Vestibular neuritis (also called Vestibular neuronitis)

Sudden onset of severe vertigo that can last for as long as a week. May be accompanied by nausea and vomiting. No neurologic or hearing symptoms, though dizziness may persist for days or weeks (Wetmore 2013; VDA 2016b)

Central nervous system diseases

 Condition-specific symptoms associated with underlying disease such as stroke, neurodegenerative disorders, or transient ischemic attacks (Frohman 2003; AHRQ 2014; Holmes 2011; Fernandez 2015)

“Vertigo” vs. “Dizziness” – What Is The Difference?

The terms “vertigo” and “dizziness” are frequently used interchangeably, though inaccurately, to refer to the same symptom. However, the terms are technically different (Post 2010).

“Vertigo” is a type of dizziness. Vertigo typically includes symptoms of dizziness, but not all cases of dizziness include the sensation of motion while not moving (vertigo). “Dizziness” is a non-specific symptom that non-medical professionals may use to describe a wide variety of conditions (Wipperman 2014).

Dizziness typically falls into one of four categories. These are vertigo, pre-syncope, disequilibrium, and lightheadedness (Susanto 2014; Post 2010). Vertigo related to inner-ear or vestibular problems (eg, positional vertigo) is a common cause of dizziness (Post 2010).

Table 2: Four Categories of Conditions That Cause Dizziness (adapted from (Susanto 2014; Post 2010; Samuels 2010))

Category

Pathophysiology

Cause(s)/Origin(s)

Vertigo

    (spinning sensation)

Problems with vestibular (inner ear) structures or balance-control regions of the brain

Vestibular neuritis; labyrinthitis; Ménière’s disease; Positional vertigo

Pre-syncope

    (fainting sensation)

Reduced blood flow to the brain

Blood volume depletion; neurocardiogenic syncope (sudden drop in heart rate or blood pressure, leading to fainting)

Disequilibrium

    (imbalance sensation)

Gait disorder

Spinal cord disease (myelopathy); peripheral neuropathy; Parkinson’s disease

Lightheadedness

    (sensation of disconnection from the environment)

Psychological disorder

Anxiety; depression

Physicians use certain tests to help identify the type of dizziness a patient is experiencing. For example, assessment of nystagmus (rapid, involuntary eye movement) with the Dix-Hallpike maneuver (see Diagnosis) can help rule out vertigo, and monitoring orthostatic blood pressure can help rule out pre-syncope due to hypotension (Post 2010).

4 Causes and Risk Factors

There are many factors that can contribute to dizziness, such as inner ear problems, medication side effects, or motion sickness. Some of these conditions can be serious, while others may be relatively minor or transient. The underlying causes and risk factors for vertigo are more finitely characterized.

Risk Factors for Vertigo

General risk factors for developing vertigo include:

  • Older age (Agrawal 2013; Neuhauser 2009)
  • Female gender (AHRQ 2014; Bisdorff 2013; Neuhauser 2009)
  • Family history of balance disorders (Gacek 2013)

Causes of Peripheral Vertigo

The most common cause of vertigo is benign paroxysmal positional vertigo, or positional vertigo (Strupp 2013; Agrawal 2013). Head injury, prolonged bed rest, and infectious inflammation of the vestibular nerve can trigger the onset of positional vertigo, although in the vast majority of cases no clear cause is ever identified (Strupp 2013).

Another common cause of vestibular vertigo is Ménière’s disease, a condition of the inner ear marked by vertigo, ringing in one or both ears (tinnitus), sensation of ear fullness, and hearing loss (Syed 2012). Possible causes of Ménière’s disease include autoimmune processes, allergy, and infection (Weinreich 2014). 

Other causes of peripheral vertigo include (Fernandez 2015; NIH 2015; Ferri 2016; Hain 2015; Cureoglu 2010; NIDCD 2013):

  • Labyrinthitis
  • Damage to the vertebral artery
  • Head and neck injuries
  • Pressure on the vestibular nerve, usually due to a non-cancerous tumor
  • Otosclerosis (hardening of middle ear structures)

Causes of Central Vertigo

Vestibular migraine. The association of migraines with vertigo may be related to a derangement in vestibular signaling and altered processing of postural and positional information (Espinosa-Sanchez 2015). In addition, migraine sufferers appear to be at higher risk of developing positional vertigo (Chu 2015), and migraines can be associated with episodes of Ménière’s disease (Foster 2015; Strupp 2013; Agrawal 2013).

Other causes of central vertigo include (NIH 2015; Fernandez 2015; Wetmore 2013; Fife 2015; Thompson 2009):

  • Cerebrovascular disease, including transient ischemic attack and stroke
  • Multiple sclerosis
  • Parkinson’s disease
  • Seizure disorder
  • Tumor
  • Drug and alcohol intoxication
  • Concussion and mild traumatic brain injury
  • Medication side effects and interactions

Table 3: Medications and Substances That may Cause Vertigo or Dizziness

Medication/Substance

Notes

Antibiotics

Cinoxacin, levoxacin, ciprofloxacin, amoxicillin + clavulanic acid, aminoglycosides, tetracyclines, amikacin, erythromycin, azithromycin, clarithromycin

Ototoxic (toxic to inner-ear structures or nerves involved in equilibration)

Diuretics

Ethacrynic acid, furosemide, hydrochlorothiazide

Related to postural hypotension; some are ototoxic

Antihypertensives

Enalapril, zofenopril, irbesartan, lacidipine, amlodipine, nifedipine, nicardipine

Due to hypotension

Cholesterol-lowering Medications

Simvastatin, atorvastatin

 

Anti-inflammatories and Pain Relievers

Aspirin, acetaminophen, ibuprofen, celecoxib, diclofenac, dexketoprofen, ketorolac, naproxen

 

Dopaminergic/Parkinson’s Disease Medications

Bromocriptine, levodopa

Bromocriptine can worsen hypotension when taken with antihypertensive medications

Anti-psychotics

Chlorpromazine, clozapine, thioridazine

May cause hypotension

Antidepressants

Mirtazapine, paroxetine, sertraline, trazodone, amitriptyline, doxepin

May cause vertigo or dizziness with or without hypotension

Anti-seizure Medications

Lamotrigine, oxcarbazepine, carbamazepine, lacosamide, clonazepam

These are also sometimes used in the treatment of vertigo

Chemotherapeutic Medications

Cisplatin

 

Antifungal and Antimalarial Medications

Amphotericin B, fluconazole, itraconazole, flucytosine, chloroquine

Ototoxic

Alcohol

May damage the vestibular system

Caffeine

 

Heavy metals and Metalloids

Arsenic, lead, mercury

Ototoxic

Tobacco

May cause dizziness, vertigo, and tinnitus

(DeWood 1990; Lin 2013; Chimirri 2013; McCormack 2003; Zanchetti 2006; Chiou 2000; Osterloh 1991; VDA 2016a)

Motion Sickness

Several sensory systems interact closely to control balance and equilibrium. These include the vestibular system or inner ear, the eyes, and receptors in the muscles and joints that sense movement and pressure. When these systems send conflicting messages about the body’s orientation and relative motion to the brain, motion sickness can occur. Motion sickness is a common problem that can cause dizziness, nausea, vomiting, fatigue, and other symptoms (Erskine 2015; American Academy of Otolaryngology 2016).

Many people experience motion sicknesses during passive motion such as while traveling by car, train, or boat. Although anyone with a functional vestibular system is theoretically susceptible to motion sickness, several factors appear to influence risk (Erskine 2015; American Academy of Otolaryngology 2016):

  • Age: children aged 2 to 12 are particularly susceptible
  • Gender: women are more likely to experience motion sickness than men, especially during pregnancy or menstruation, or while using hormone replacement therapy
  • Migraines: migraineurs have increased susceptibility to motion sickness
  • Medication use: several types of medication may increase motion sickness risk. These include antibiotics, estrogens, some cardiovascular medications (eg, digoxin), narcotic pain killers, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, some asthma medications, and bisphosphonates

Some medications may help relive motion sickness symptoms. These include antihistamines, scopolamine, antidopaminergic drugs, metoclopramide (Reglan), sympathomimetics, and benzodiazepines. Unfortunately, many of these medications can cause side effects such as drowsiness (Erskine 2015; American Academy of Otolaryngology 2016).  

In some cases, motion sickness can be prevented or relieved by specific actions such as lying down, shutting the eyes, avoiding sitting in the rear of the vehicle, not reading while traveling, and looking at the horizon. Staying adequately hydrated, eating small meals, and avoiding alcohol before travel may also help. Distractions such as listening to music or sucking on lozenges may be useful as well. Ginger-flavored lozenges in particular may be helpful because ginger can promote gastric emptying (Lazzini 2016; Marx 2015), which is sometimes delayed in motion sickness (Erskine 2015).

5 Conditions Associated With Vertigo and Dizziness

Vertigo and dizziness are associated with several systemic disorders. While the connections between some particular health conditions and vertigo or dizziness are well understood (eg, orthostatic hypotension and dizziness) (Kim 2015), other associations remain the subject of intriguing ongoing research. Some of these associations will be reviewed here.

Abnormal Glucose Metabolism

Vertigo, particularly that caused by Ménière’s disease, is associated with abnormalities of glucose and insulin metabolism (Kraft 1998; Kirtane 1984; D'Avila 2005; Mangabeira Albernaz 1984; Lehrer 1986; Serra 2009). In fact, people with diabetes may have up to 70% higher risk of a balance disorder (Agrawal 2013), and high glucose and insulin levels have been associated with increased risk of positional vertigo recurrence (Webster 2015).

It has been proposed that chronic blood glucose elevation damages the blood vessels and nerves that supply the vestibular system, leading to degeneration of vestibular tissues. At the same time, the inner ear is rich in insulin receptors and therefore sensitive to insulin levels. Chronically elevated insulin levels may affect inner ear blood flow, disrupting the complex chemical balance of inner ear fluids and resulting in vestibular dysfunction (Webster 2015). More information about diabetes and glucose control is available in Life Extension’s Diabetes protocol.

Osteoporosis

There is some evidence that low bone mineral density (osteopenia) and osteoporosis are associated with positional vertigo (Yu 2014). In one study, women with osteoporosis and positional vertigo were more than three times as likely to have recurrent vertigo than women without osteoporosis, and the rate of recurrence increased as bone mineral density decreased (Yamanaka 2013). In another study, osteoporosis treatment correlated with a lower risk of positional vertigo in women 51‒60 years old (Mikulec 2010). Some researchers have proposed that the association between positional vertigo and bone loss may be related to vitamin D deficiency (Talaat, Abuhadied 2015). For more information about bone health see Life Extension’s Osteoporosis protocol.

Sleep Apnea

In a preliminary study, adults with dizziness of unknown origin were more likely to report symptoms suggestive of sleep apnea than people without dizziness (Sowerby 2010). In other research, individuals with moderate-to-severe obstructive sleep apnea reported greater vertigo-related disability than those with mild sleep apnea (Kayabasi 2015). And patients with sleep apnea and Ménière’s disease experienced a reduction in Ménière’s disease symptoms when their sleep apnea was treated with a continuous positive airway pressure (CPAP) device (Nakayama 2015). New evidence suggests repeated bouts of low oxygen levels that accompany sleep apnea may damage the vestibular system (Kayabasi 2015; Gallina 2010), which could increase risk of peripheral vertigo. Refer to Life Extension’s Sleep Apnea protocol for more information.

Depression and Other Mental Health Issues

There is a high prevalence of anxiety, depression, and other emotional, psychiatric, and cognitive disorders in people with vertigo (Peluso 2015; Bigelow 2015; Ketola 2015; Lahmann 2015). Some researchers have proposed that the vestibular system, in addition to supporting balance control, may participate in perception, cognition, and consciousness. Vestibular dysfunction may therefore play an important role in psychiatric and cognitive disorders, even in the absence of vertigo (Gurvich 2013). For more information, refer to Life Extension’s protocols on anxiety, depression, and obsessive-compulsive disorder.

6 Diagnosis

Dizziness

Because many health conditions can cause dizziness, physicians must systematically exclude diagnostic possibilities during evaluation of patients who present with dizziness. Ruling out urgent causes of vertigo and dizziness, such as stroke, is vital (Kerber 2009b; Tarnutzer 2011; von Brevern 2015; Lin 2013). Sudden onset of severe dizziness accompanied by neurologic symptoms such as numbness or weakness of a limb or the face, difficulty swallowing, or speech or language difficulties may indicate stroke (Wetmore 2013).

Usually, the initial differential diagnosis involves ruling out the most common causes of dizziness, such as positional vertigo and orthostatic hypotension. If the cause of dizziness is not then immediately obvious, physicians may try to categorize each case to facilitate further diagnostic precision. Categories (Table 2) of dizziness include vertigo, pre-syncope, disequilibrium, and lightheadedness (Susanto 2014; Post 2010; Samuels 2010; Hogue 2015). A newer approach has been proposed as well, based upon the timing and triggers of dizziness (Edlow 2016). This strategy groups cases into one of three categories: vestibular syndrome, common benign causes (eg, positional vertigo), and dangerous causes (eg, stroke).

The patient’s eyes are often helpful in the evaluation of dizziness. Nystagmus (involuntary, rapid eye movements) may manifest differently depending on the cause of dizziness; diligent clinicians may be able to rule out certain causes of dizziness upon observation of the pattern of nystagmus or other eye movement abnormalities (Edlow 2016). However, the utility of this approach depends in large part on the level of physician knowledge and also the time he or she takes in evaluating the patient. 

Vertigo

A specialized maneuver called the Dix-­Hallpike test utilizes rapid head rotation while moving from a seated to lying position, and may help diagnose positional vertigo. If the maneuver recreates vertigo and a particular pattern of nystagmus, it points to positional vertigo as the cause (AHRQ 2014; Vanni 2014).

Blood tests are generally not necessary in the diagnosis of dizziness and vertigo, though they may help detect abnormalities such as anemia, infection, and thyroid or autoimmune disease. Additional diagnostic tests such as MRI and CT scans are indicated when central causes are suspected, while hearing tests may help differentiate among possible causes of vertigo (Vanni 2014; AHRQ 2014; Strupp 2008; Wetmore 2013).

7 Treatment

The treatment approach to a patient with a history or presentation of dizziness can vary considerably. Dizziness is not a disease outright, but a possible manifestation of many diseases. Therefore, how a patient with dizziness is treated depends on the cause of his or her dizziness.

For vertigo, specific treatment approaches are more well delineated and are based upon the cause:

Positional Vertigo

With no treatment, over 60% of positional vertigo patients recover within four weeks; however, an estimated 58% of women and 39% of men experience recurrent episodes (Strupp 2013). Maneuvers designed to move debris out of the semicircular canals are frequently used to treat positional vertigo (Holmes 2011). The Semont and Epley maneuvers are among the most widely used and are effective in the majority of cases (Agrawal 2013; Strupp 2013; Iwasaki 2015; Agus 2013).

Antihistamines and benzodiazepines may delay resolution of symptoms in positional vertigo, and the American Academy of Otolaryngology recommends against their routine use in this condition (Foster 2015; Lin 2013; Wetmore 2013; VDA 2016a; Bhattacharyya 2008).

Vestibular Migraine

Vestibular migraine (sometimes called migraine-associated vertigo) is managed similarly to migraine headaches (VDA 2016c). This includes the use of migraine medications including triptans (eg, zolmitriptan [Zomig]); beta-blockers (eg, propranolol [Inderal] or metoprolol [Lopressor]); and anti-seizure medications (eg, topiramate [Topamax] and valproic acid [Depakene]) (Obermann 2014; Wetmore 2013; Strupp 2013). Other medical treatments may include antihistamines, anticholinergics, benzodiazepines, or anti-emetics (Hain 2003; VDA 2016a; Hain 2008).

Ménière’s Disease

Diuretic medications are commonly used to treat Ménière’s disease. However, one thorough literature review found little evidence from controlled clinical trials supporting the use of medications to treat Ménière’s, prevent attacks, or delay progression (Berlinger 2011; Foster 2015; Burgess 2006; Syed 2012; James 2007).

Oral steroids have been used to treat Ménière’s, with one study finding that 18 months of treatment reduced the frequency of vertigo spells by 50% (Foster 2015). The corticosteroid dexamethasone and the antibiotic gentamicin (Garamycin) can be injected past the eardrum into the middle and inner ear in patients who do not respond to more conservative treatment (Foster 2015; Berlinger 2011; Syed 2012; Wetmore 2013). Other medical treatments may include antihistamines, anticholinergics, benzodiazepines, or anti-emetics (Hain 2003; VDA 2016a; Hain 2008).

Other Treatment Considerations

Vestibular rehabilitation. Vestibular rehabilitation may improve balance and stability in people with intractable peripheral or central vertigo by encouraging the nervous system to adapt to changes in nerve signaling within the balance control network (Fernandez 2015; Iwasaki 2015; Kornilova 2010; Barona de Guzman 1994). These exercises address stabilization of vision, coordination of head and eye movement, and postural control through biofeedback techniques, and can be tailored to the individual (Barona de Guzman 1994; Mraz 2007).

Surgery. Surgery is available as a last resort to treat intractable peripheral vertigo (Sennaroglu 2001; Sismanis 2010). In rare cases, surgery is used to address vertigo caused by structural vestibular problems, including tumors (Holmes 2011).

8 Novel and Emerging Strategies

Treating Jugular Vein Abnormalities

Structural abnormalities in the jugular vein, which passes very close to sensitive vestibular structures, may contribute to some cases of Ménière’s disease and vertigo. In a report on three cases, jugular bulb abnormalities were corrected with non-surgical placement of coils and stents, resulting in a complete resolution of vertigo symptoms over 12‒24 months of follow up (Park 2015; Hitier 2014).

Flunarizine

Flunarizine is a calcium channel blocker and antihistamine drug that is approved in many countries for migraine prevention. As of early 2016, it is not approved for any indication in the United States (NICE 2016; GOSH 2015; Health Canada 2015; Shamliyan 2013). Flunarizine has been demonstrated, in a randomized controlled trial, to be an effective adjunct treatment for migraine-associated vertigo. In 48 patients over 12 weeks, treatment with flunarizine, betahistine, and acetaminophen was compared with betahistine and acetaminophen alone. There was a significant decrease in frequency and severity of episodes of migrainous vertigo in the flunarizine group, and no significant difference in the frequency of adverse effects between the two groups (Lepcha 2014).

Serum Protein S100-beta

In emergency care settings, it is critical to differentiate benign or peripheral vertigo from acute stroke. Serum protein S100-beta is a novel diagnostic biomarker that has been studied for a variety of conditions affecting the central nervous system, including traumatic brain injury, stroke, and mood disorders. This protein is found in greater quantities in serum when neurological damage has occurred, and thus can help identify neurological origins of some symptoms (Yardan 2011). Emerging findings suggest this protein may someday be used in acute care settings to differentiate vertigo caused by vascular stroke from vertigo due to non-vascular causes (Kartal 2014; Purrucker 2014; Lynch 2004; Bouvier 2013; Schroeter 2013; Mercier 2013; Egea-Guerrero 2012).

Ocular and Cervical Vestibular Evoked Myogenic Potentials

Vestibular evoked myogenic potentials are electrical signals that can be measured in the neck or eye muscles and that may provide valuable diagnostic information about the causes of vertigo. In this procedure, the ear is stimulated with sound or vibration, which results in measurable electrical impulses in neck (cervical) or ocular muscles. These tests measure function of the vestibular otoliths in the inner ear. This approach is gaining popularity and may help refine the diagnosis of vertigo (Rosengren 2013; Young 2013; Murofushi 2011; Murofushi 2016; Venhovens 2016; Hong 2008; Burkard 2013).

Repositioning Therapies

Physical therapies that induce the movement of crystals out of the semicircular canals are effective for treating positional vertigo. The half somersault maneuver is a novel technique developed for at-home use without assistance. The half somersault maneuver was compared to the Epley maneuver (a well-known technique for crystal repositioning) in 68 people with positional vertigo. Those who used the half somersault experienced less dizziness and other complications during the procedure. They were also more likely to remain in remission six months after treatment (Foster 2012). A how-to guide for performing the half somersault maneuver has been developed by Carol Foster, MD and is available on her website.

Biofeedback Therapy

Another promising field of research for individuals with vertigo is biofeedback therapy. Specific biofeedback techniques can be integrated into vestibular rehabilitation programs through the use of computer-generated cues about posture and position that encourage adaptation and improved balance (Kornilova 2010). In one study, five weeks of twice-weekly biofeedback therapy reduced swaying and instability and decreased reaction times in 73% of the 37 vertigo-affected participants (Perez 2006). Similar positive results have been observed in several other studies (Mraz 2007; Luchikhin 2002; Shutty 1991).

9 Diet And Lifestyle Considerations

Diet

A low-sodium diet is a well-established treatment for Ménière’s disease (Foster 2015; Berlinger 2011). Some evidence suggests large fluctuations in sodium intake may exacerbate symptoms in certain cases of Ménière’s. Consistent moderate sodium restriction may be effective in such cases (Rauch 2010; Foster 2015).

Certain food additives or constituents may trigger migraines in susceptible individuals. These include nitrates, nitrites, tyramine, aspartame, monosodium glutamate, or sulfites, as well as caffeine and alcohol (Sun-Edelstein 2009; Millichap 2003). Examples of common foods that contain these migraine triggers include red wine, beer, chocolate, cheese, aged or pickled foods, citrus, and dried fruits (Foster 2015; Millichap 2003; Leclercq 2000). Some practitioners advise patients under the age of 50 who have Ménière’s disease to eliminate these foods (Foster 2015). More information is available in Life Extension’s Migraine protocol.

Some studies have discovered an association between positional vertigo and abnormalities in glucose and insulin metabolism. A diet rich in whole foods from plants, such as the Mediterranean Diet, which helps improve blood sugar metabolism, may have potential as an adjunctive treatment in positional vertigo (Agrawal 2013; Schultz 2015; Webster 2015; De Natale 2009; Nadeau 2014; Esposito 2015).

Relaxation Techniques

Individuals suffering from vertigo are more likely to experience depression and anxiety or another psychological condition (Lahmann 2015). Autogenic training, a body-mind technique that uses imagery and body awareness to induce a relaxed state (UMMC 2013b), has shown promise in case reports and preliminary research in people with Ménière’s disease and psychogenic vertigo (Goto 2011; Goto 2008b; Goto 2008a). Relaxation techniques such as mindfulness-based stress reduction, relaxation response training, and cognitive-behavioral stress management have shown therapeutic benefits in managing emotional stress (Crawford 2013), and may prove useful for treating vertigo-related conditions. Life Extension’s Stress Management protocol describes additional relaxation strategies.

Manual Therapies

Some research indicates manual spinal mobilization may effectively treat some types of dizziness (Bronfort 2010). Case studies have highlighted its potential benefit in individuals with Ménière’s disease and vertigo after brain surgery (Emary 2010; Haller 2015).

A pilot trial found manual therapy performed by a physician reduced symptoms in 16 subjects with vertigo lasting three months or longer (Fraix 2010). Other research has shown that accurate diagnosis and treatment of cervical spine dysfunction with manual mobilization methods can effectively alleviate vertigo (Galm 1998; Fang 2010; Heikkila 2000). In one study, physiotherapy treatment was more effective than medication for relieving cervical vertigo (vertigo induced by particular neck positioning) (Olszewski 2007).

Acupuncture

In a series of case reports, 49 of 50 subjects with vertigo caused by poor circulation to certain parts of the brain were treated with multiple acupuncture methods, and 39 of those cases exhibited complete resolution of symptoms (Huang 2009).

One report on 34 cases of Ménière’s disease treated with acupuncture recorded symptomatic improvement in all cases (Steinberger 1983). Results from a pilot trial in patients with cervical vertigo suggest electroacupuncture may be a useful addition to regular acupuncture for this condition (Li 2011).

10 Integrative Interventions

Primary Support

Vitamin D. Low vitamin D status has been observed in patients with positional vertigo, especially in those with chronic recurrent vertigo (Buki 2013; Talaat, Abuhadied 2015). In one study, subjects with vitamin D levels between 10 and 20 ng/mL had 3.8-fold greater odds of having positional vertigo compared with controls whose levels were above 20 ng/mL, while those with vitamin D levels below 10 ng/mL had 23 times the odds of positional vertigo (Jeong 2013).

One study in adults with positional vertigo found vitamin D supplementation eliminated vertigo episodes in all study subjects. Ten study participants with vitamin D levels below 20 ng/mL were treated with 8000 IU of vitamin D daily for two weeks, then 4000 IU daily for two weeks, followed by weekly doses of 8000 IU. Although some of these participants experienced multiple episodes of vertigo in the past, there were no recurrences between the time of initiating vitamin D therapy and the end of the eight-month study period (Buki 2013). Another study of 93 subjects with positional vertigo and severe vitamin D deficiency (≤ 10 ng/mL) found the degree of improvement of severe vitamin D deficiency after treatment predicted symptomatic response. Among those whose vitamin D level improved by less than 10 ng/mL, 43% experienced an episode of vertigo. However, among those whose vitamin D status improved by 10 ng/mL or more, only 14% experienced a vertigo recurrence (Talaat, Kabel 2015).

Ginkgo biloba. Ginkgo biloba, one of the oldest living species of trees in the world, is used in many countries for the treatment for vertigo (Agus 2013; UMMC 2013a). In a 12-week randomized controlled trial in 160 subjects with peripheral vertigo, 240 mg ginkgo extract daily was more effective and better tolerated than 32 mg daily of betahistine, a medication sometimes used to treat vertigo (Sokolova 2014). In an earlier trial, 160 mg of ginkgo extract per day for three months was also as effective as 32 mg per day of betahistine in people with vertigo related to vestibular disorders (Cesarani 1998). Another three-month trial found treatment with a ginkgo extract led to complete symptomatic improvement in 47% of a group of patients with vertigo of unknown origin, compared with 18% of those given placebo (Haguenauer 1986). In 30 individuals with an average age of 33.5 years who suffered from headache and memory and cognitive difficulties, 40 mg of ginkgo extract three times daily reduced vertigo intensity (Naprienko 2014), while another trial found ginkgo extract was successful in speeding rehabilitation in people with vestibular damage (Orendorz-Fraczkowska 2002).

Gastrodin. Gastrodia elata is a type of orchid used in traditional Chinese medicine to treat conditions including vertigo, epilepsy, headache, and pain (Li 2004; Ramachandran 2012). A rigorous analysis of controlled clinical trials that used injections of gastrodin, an extract from the gastrodia plant, to treat vertigo concluded that this treatment was more effective than medication (Ye 2009), and when given with the anti-nausea medication promethazine (Phenergan), can relieve acute emergency vertigo (Xu 2013). Laboratory studies have found gastrodia extract is able to protect nerve cells from inflammatory damage and promote neuroregenerative processes (Kim 2012; Ramachandran 2012).

Vertigoheel. Vertigoheel is a homeopathic product that has been studied for the treatment of vertigo. It is composed of dilute preparations of a combination of the conium and cocculus plants, ambergris, and mineral oil (DailyMed 2016). A laboratory study found Vertigoheel has vasorelaxant properties and appears to stimulate cyclic nucleotide pathways, while a clinical study found that treatment influenced microcirculation and improved oxygenation of the blood (Heinle 2010; Klopp 2005). In an uncontrolled trial in which patients with vertigo took three tablets of Vertigoheel three times daily for 14 days, 57.5% of participants reported improvement, which was confirmed by objective sensory motor tests (Claussen 1984). Another clinical trial treated different types of vertigo with Vertigoheel and found improvement in symptoms in the majority of cases (Morawiec-Bajda 1993). Vertigoheel has been compared to other established vertigo treatments such as Ginkgo biloba, betahistine, and dimenhydrinate, and found to have comparable efficacy (Issing 2005; Schneider 2005).

Additional Support

Coenzyme Q10. Coenzyme Q10 (CoQ10) supplementation has been shown to be of benefit in vertigo (Kumar 2009). CoQ10 is centrally involved in cellular energy production in the mitochondria and has been studied for the treatment of cardiovascular disease (Genova 2011; Yang 2015). In one trial, 2664 patients with congestive heart failure were treated with 50–150 mg per day of CoQ10. After three months of treatment, 73% of participants with vertigo reported improvement in their vertigo (Baggio 1994). CoQ10 is also thought to protect the inner ear structures, potentially preventing vestibular disorders that can lead to vertigo (Someya 2009; Iwasaki 2015).

Glutathione and related nutrients. A study in 22 treatment-resistant patients with Ménière’s disease evaluated 300 mg per day of rebamipide (an oxidative stress medication not available in the United States) along with 600 mg per day of vitamin C and/or 300 mg per day of glutathione. The treatment lasted eight weeks or more. Twenty-one of the 22 patients with vertigo reported complete recovery or substantial improvement 12 months after treatment (Takumida 2003). Based on these results, nutrient supplements that can increase glutathione levels, such as L-cysteine, vitamin C, whey protein, selenium, and N-acetylcysteine, may have a role in the treatment of vertigo and Ménière’s disease (Middleton 2004; Bounous 1989; Kent 2003; Arakawa 2007; Johnston 1993; Ballatori 2009).

Vitamin B12. Vitamin B12 is essential for normal neurological function, and B12 deficiency can cause a wide range of neurological and psychiatric symptoms, including vertigo and dizziness (Clarke 2003; Briani 2013). In a case report, an elderly patient with dizziness and imbalance was found to have vitamin B12 deficiency and elevated homocysteine levels. B12 injection therapy resulted in a dramatic response in this patient (Singh 2010). A study in 100 people with neurological symptoms that included dizziness and instability found that 15% of subjects had low vitamin B12 levels (Mahajan 2015).

Vitamin B6. Vitamin B6 supplementation may be helpful in certain cases of medication-related vertigo. In two separate double-blind clinical trials, 20 healthy individuals took the antibiotic minocycline (Minocin) seven times over three days in order to induce vertigo, nystagmus, and nausea. The addition of 40 mg of vitamin B6 at each dose markedly reduced these side effects (Claussen 1988).

Ginger root. Zingiber officinale (ginger) root has been used traditionally to treat digestive, inflammatory, and infectious ailments (Haniadka 2013). A randomized controlled trial found one gram of powdered ginger strongly prevented symptoms of seasickness, including vertigo (Grontved 1988). Another placebo-controlled clinical trial showed ginger prevented vertigo significantly better than placebo in healthy adult subjects who underwent vestibular stimulation to induce vertigo (Grontved 1986).

Magnesium. Migraine can be effectively treated with oral magnesium supplementation (Obermann 2014; Peikert 1996; Chiu 2016), and magnesium supplementation may be beneficial in migraine-associated vertigo. A thorough analysis of randomized clinical trials found that, in cardiac patients, magnesium orotate supplementation reduced the risk of dizziness by 78% (Torshin 2015). Magnesium modulates smooth muscle tone in blood vessels (Kolte 2014), suggesting it might favorably impact vertigo related to vestibular blood flow restriction.

AAFM. American Academy of Family Physicians. Information from your family doctor. Vertigo--a type of dizziness. American family physician. Mar 15 2005;71(6):1129-1130.

Agrawal Y, Ward BK, Minor LB. Vestibular dysfunction: prevalence, impact and need for targeted treatment. Journal of vestibular research : equilibrium & orientation. 2013;23(3):113-117.

Agus S, Benecke H, Thum C, Strupp M. Clinical and Demographic Features of Vertigo: Findings from the REVERT Registry. Frontiers in neurology. 2013;4:48.

AHRQ. Agency for Healthcare Research and Quality. Guideline Summary: Evaluation of vertigo in the adult patient. http://www.guideline.gov/content.aspx?id=48220. 5/2014. Accessed 1/20/2016.

American Academy of Otolaryngology. Patient Health page. Dizziness and Motion Sickness. http://www.entnet.org/content/dizziness-and-motion-sickness. Copyright 2016. Accessed 4/25/2016.

Arakawa M, Ito Y. N-acetylcysteine and neurodegenerative diseases: basic and clinical pharmacology. Cerebellum (London, England). 2007;6(4):308-314.

Baggio E, Gandini R, Plancher AC, Passeri M, Carmosino G. Italian multicenter study on the safety and efficacy of coenzyme Q10 as adjunctive therapy in heart failure. CoQ10 Drug Surveillance Investigators. Molecular aspects of medicine. 1994;15 Suppl:s287-294.

Ballatori N, Krance SM, Notenboom S, Shi S, Tieu K, Hammond CL. Glutathione dysregulation and the etiology and progression of human diseases. Biological chemistry. 2009;390(3):191-214.

Barona de Guzman R, Armengot Carceller M. [Vestibular compensation. Rehabilitation of a patient with vertigo]. Acta otorrinolaringologica espanola. Nov-Dec 1994;45(6):401-405.

Berlinger NT. Meniere's disease: new concepts, new treatments. Minnesota medicine. Nov 2011;94(11):33-36.

Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, . . . Haidari J. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. Nov 2008;139(5 Suppl 4):S47-81.

Bigelow RT, Semenov YR, du Lac S, Hoffman HJ, Agrawal Y. Vestibular vertigo and comorbid cognitive and psychiatric impairment: the 2008 National Health Interview Survey. Journal of neurology, neurosurgery, and psychiatry. Apr 17 2015.

Bisdorff A, Bosser G, Gueguen R, Perrin P. The epidemiology of vertigo, dizziness, and unsteadiness and its links to co-morbidities. Frontiers in neurology. 2013;4:29-29.

Bounous G, Gervais F, Amer V, Batist G, Gold P. The influence of dietary whey protein on tissue glutathione and the diseases of aging. Clinical and investigative medicine. Medecine clinique et experimentale. Dec 1989;12(6):343-349.

Bouvier D. [Interest of S100B protein blood level determination in severe or moderate head injury]. Ann Biol Clin (Paris). Mar-Apr 2013;71(2):145-150.

Briani C, Dalla Torre C, Citton V, Manara R, Pompanin S, Binotto G, Adami F. Cobalamin deficiency: clinical picture and radiological findings. Nutrients. Nov 2013;5(11):4521-4539.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & osteopathy. 2010;18:3.

Buki B, Ecker M, Junger H, Lundberg YW. Vitamin D deficiency and benign paroxysmal positioning vertigo. Medical hypotheses. Feb 2013;80(2):201-204.

Burgess A, Kundu S. Diuretics for Meniere’s disease or syndrome. The Cochrane database of systematic reviews. 2006;3.

Burkard R, Shepard N. Vestibular evoked myogenic potentials: They are the same as an auditory evoked potential, only different. [slides]. http://www.mayo.edu/mayo-edu-docs/mayo-clinic-audiology-conference-documents/burkard-shepard-handout.pdf. 2/9/2013. Accessed 2/3/2016.

Campellone JV. U.S. National Library of Medicine. Vertigo-associated disorders. https://www.nlm.nih.gov/medlineplus/ency/article/001432.htm. Last updated 10/29/2013. Accessed 2/18/2016.

Cesarani A, Meloni F, Alpini D, Barozzi S, Verderio L, Boscani PF. Ginkgo biloba (EGb 761) in the treatment of equilibrium disorders. Advances in therapy. Sep-Oct 1998;15(5):291-304.

Chimirri S, Aiello R, Mazzitello C, Mumoli L, Palleria C, Altomonte M, . . . De Sarro G. Vertigo/dizziness as a Drugs' adverse reaction. Journal of pharmacology & pharmacotherapeutics. Dec 2013;4(Suppl 1):S104-109.

Chiou KR, Chen CH, Ding PY, Chen YT, Ting CT, Huang JL, . . . Chang MS. Randomized, double-blind comparison of irbesartan and enalapril for treatment of mild to moderate hypertension. Zhonghua yi xue za zhi = Chinese medical journal; Free China ed. May 2000;63(5):368-376.

Chiu HY, Yeh TH, Huang YC, Chen PY. Effects of Intravenous and Oral Magnesium on Reducing Migraine: A Meta-analysis of Randomized Controlled Trials. Pain physician. Jan 2016;19(1):E97-e112.

Chu CH, Liu CJ, Lin LY, Chen TJ, Wang SJ. Migraine is associated with an increased risk for benign paroxysmal positional vertigo: a nationwide population-based study. The journal of headache and pain. Dec 2015;16:62.

Clarke R, Refsum H, Birks J, Evans JG, Johnston C, Sherliker P, . . . Scott JM. Screening for vitamin B-12 and folate deficiency in older persons. The American journal of clinical nutrition. May 2003;77(5):1241-1247.

Claussen CF, Bergmann J, Bertora G, Claussen E. [Clinical experimental test and equilibrimetric measurements of the therapeutic action of a homeopathic drug consisting of ambra, cocculus, Conium and mineral oil in the diagnosis of vertigo and nausea]. Arzneimittel-Forschung. 1984;34(12):1791-1798.

Claussen CF, Claussen E. [Antivertiginous action of vitamin B 6 on experimental minocycline-induced vertigo in man]. Arzneimittel-Forschung. Mar 1988;38(3):396-399.

Crawford C, Wallerstedt DB, Khorsan R, Clausen SS, Jonas WB, Walter JA. A systematic review of biopsychosocial training programs for the self-management of emotional stress: potential applications for the military. Evidence-based complementary and alternative medicine : eCAM. 2013;2013:747694.

Cureoglu S, Baylan MY, Paparella MM. Cochlear Otosclerosis. Current opinion in otolaryngology & head and neck surgery. 2010;18(5):357-362.

D'Avila C, Lavinsky L. Glucose and insulin profiles and their correlations in Meniere's disease. The international tinnitus journal. 2005;11(2):170-176.

DailyMed. Archived Drug Label. Vertigoheel. https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=148998. Accessed 3/28/2016.

De Natale C, Annuzzi G, Bozzetto L, Mazzarella R, Costabile G, Ciano O, . . . Rivellese AA. Effects of a plant-based high-carbohydrate/high-fiber diet versus high-monounsaturated fat/low-carbohydrate diet on postprandial lipids in type 2 diabetic patients. Diabetes care. Dec 2009;32(12):2168-2173.

Demetroulakos JL, Scherger JE. First Consult. Ménière disease. www.clinicalkey.com. 10/14/2010. Accessed 1/20/2016.

DeWood MA, Wolbach RA. Randomized double-blind comparison of side effects of nicardipine and nifedipine in angina pectoris. The Nicardipine Investigators Group. American heart journal. Feb 1990;119(2 Pt 2):468-478.

Edlow JA, Newman-Toker D. Using the Physical Examination to Diagnose Patients with Acute Dizziness and Vertigo. The Journal of emergency medicine. Apr 2016;50(4):617-628.

Egea-Guerrero JJ, Revuelto-Rey J, Murillo-Cabezas F, Munoz-Sanchez MA, Vilches-Arenas A, Sanchez-Linares P, . . . Leon-Carrion J. Accuracy of the S100beta protein as a marker of brain damage in traumatic brain injury. Brain injury. 2012;26(1):76-82.

Emary PC. Chiropractic management of a 40-year-old female patient with Meniere disease. Journal of chiropractic medicine. Mar 2010;9(1):22-27.

Erskine SK. The Pre-Travel Consultation. Chapter 2. Jet Lag: Motion Sickness. Centers for Disease Control and Prevention [online]. http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/motion-sickness. Last updated 7/10/2015. Accessed 4/25/2016.

Espinosa-Sanchez JM, Lopez-Escamez JA. New insights into pathophysiology of vestibular migraine. Frontiers in neurology. 2015;6:12.

Esposito K, Maiorino MI, Bellastella G, Chiodini P, Panagiotakos D, Giugliano D. A journey into a Mediterranean diet and type 2 diabetes: a systematic review with meta-analyses. BMJ open. 2015;5(8):e008222.

Fang J. [Observation of curative effect on fixed-point spin reduction of spinal manipulation therapy for cervical vertigo]. Zhongguo gu shang = China journal of orthopaedics and traumatology. Feb 2010;23(2):99-101.

Fernandez L, Breinbauer HA, Delano PH. Vertigo and Dizziness in the Elderly. Frontiers in neurology. 2015;6:144.

Ferri FF. Ferri's Clinical Advisor. Labyrinthitis. pp. 735-735e1. www.clinicalkey.com. Copyright 2016. Accessed 2/18/2016.

Fife TD, Kalra D. Persistent vertigo and dizziness after mild traumatic brain injury. Annals of the New York Academy of Sciences. Apr 2015;1343:97-105.

Foster CA. Optimal management of Meniere's disease. Therapeutics and clinical risk management. 2015;11:301-307.

Foster CA, Ponnapan A, Zaccaro K, Strong D. A Comparison of Two Home Exercises for Benign Positional Vertigo: Half Somersault versus Epley Maneuver. Audiology and Neurotology Extra. 2012;2(1):16-23.

Fraix M. Osteopathic manipulative treatment and vertigo: a pilot study. PM & R : the journal of injury, function, and rehabilitation. Jul 2010;2(7):612-618.

Frohman EM, Kramer PD, Dewey RB, Kramer L, Frohman TC. Benign paroxysmal positioning vertigo in multiple sclerosis: diagnosis, pathophysiology and therapeutic techniques. Multiple sclerosis (Houndmills, Basingstoke, England). Jun 2003;9(3):250-255.

Gacek RR. A perspective on recurrent vertigo. ORL; journal for oto-rhino-laryngology and its related specialties. 2013;75(2):91-107.

Gallina S, Dispenza F, Kulamarva G, Riggio F, Speciale R. Obstructive sleep apnoea syndrome (OSAS): effects on the vestibular system. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale. Dec 2010;30(6):281-284.

Galm R, Rittmeister M, Schmitt E. Vertigo in patients with cervical spine dysfunction. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 1998;7(1):55-58.

Genova ML, Lenaz G. New developments on the functions of coenzyme Q in mitochondria. BioFactors (Oxford, England). Sep-Oct 2011;37(5):330-354.

GOSH. Great Ormond Street Hospital for Children. Flunarizine to prevent migraine. http://www.gosh.nhs.uk/medical-information/medicines-information/flunarizine-prevent-migraine. Copyright 2015. Accessed 1/21/2016.

Goto F, Nakai K, Kunihiro T, Ogawa K. Case report: a case of intractable Meniere's disease treated with autogenic training. BioPsychoSocial medicine. 2008a;2:3.

Goto F, Nakai K, Kunihiro T, Ogawa K. Phobic postural vertigo treated with autogenic training: a case report. Cases journal. 2008b;1(1):189.

Goto F, Nakai K, Ogawa K. Application of autogenic training in patients with Meniere disease. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. Oct 2011;268(10):1431-1435.

Grontved A, Brask T, Kambskard J, Hentzer E. Ginger root against seasickness. A controlled trial on the open sea. Acta oto-laryngologica. Jan-Feb 1988;105(1-2):45-49.

Grontved A, Hentzer E. Vertigo-reducing effect of ginger root. A controlled clinical study. ORL; journal for oto-rhino-laryngology and its related specialties. 1986;48(5):282-286.

Gurvich C, Maller JJ, Lithgow B, Haghgooie S, Kulkarni J. Vestibular insights into cognition and psychiatry. Brain Res. Nov 6 2013;1537:244-259.

Haguenauer JP, Cantenot F, Koskas H, Pierart H. [Treatment of equilibrium disorders with Ginkgo biloba extract. A multicenter double-blind drug vs. placebo study]. Presse medicale (Paris, France : 1983). Sep 25 1986;15(31):1569-1572.

Hain TC. American Hearing Research Foundation. Hearing & Balance Disorders. Medical Treatment of Vertigo. http://american-hearing.org/disorders/medical-treatment-of-vertigo/. Last updated 10/2008. Accessed 3/28/2016.

Hain TC. Cervicogenic causes of vertigo. Current opinion in neurology. Feb 2015;28(1):69-73.

Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS drugs. 2003;17(2):85-100.

Haller H, Cramer H, Werner M, Dobos G. Treating the sequelae of postoperative meningioma and traumatic brain injury: a case of implementation of craniosacral therapy in integrative inpatient care. Journal of alternative and complementary medicine (New York, N.Y.). Feb 2015;21(2):110-112.

Haniadka R, Saldanha E, Sunita V, Palatty PL, Fayad R, Baliga MS. A review of the gastroprotective effects of ginger (Zingiber officinale Roscoe). Food & function. Jun 2013;4(6):845-855.

Health Canada. Flunarizine. http://www.drugbank.ca/drugs/DB04841. Last updated 1/26/2015. Accessed 1/21/2016.

Heikkila H, Johansson M, Wenngren BI. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Manual therapy. Aug 2000;5(3):151-157.

Heinle H, Tober C, Zhang D, Jaggi R, Kuebler WM. The low-dose combination preparation Vertigoheel activates cyclic nucleotide pathways and stimulates vasorelaxation. Clinical hemorheology and microcirculation. 2010;46(1):23-35.

Hitier M, Barbier C, Marie-Aude T, Moreau S, Courtheoux P, Patron V. New treatment of vertigo caused by jugular bulb abnormalities. Surg Innov. Aug 2014;21(4):365-371.

Hogue JD. Office evaluation of dizziness. Primary care. Jun 2015;42(2):249-258.

Holmes S, Padgham ND. A review of the burden of vertigo. J Clin Nurs. Oct 2011;20(19-20):2690-2701.

Hong SM, Yeo SG, Kim SW, Cha CI. The results of vestibular evoked myogenic potentials, with consideration of age-related changes, in vestibular neuritis, benign paroxysmal positional vertigo, and Meniere's disease. Acta oto-laryngologica. Aug 2008;128(8):861-865.

Huang Q. Fifty cases of vertebrobasilar ischemic vertigo treated by acupuncture. Journal of traditional Chinese medicine = Chung i tsa chih ying wen pan / sponsored by All-China Association of Traditional Chinese Medicine, Academy of Traditional Chinese Medicine. Jun 2009;29(2):87-89.

Issing W, Klein P, Weiser M. The homeopathic preparation Vertigoheel versus Ginkgo biloba in the treatment of vertigo in an elderly population: a double-blinded, randomized, controlled clinical trial. Journal of alternative and complementary medicine (New York, N.Y.). Feb 2005;11(1):155-160.

Iwasaki S, Yamasoba T. Dizziness and Imbalance in the Elderly: Age-related Decline in the Vestibular System. Aging Dis. Feb 2015;6(1):38-47.

James AL, Thorp MA. Menière's disease. BMJ Clinical Evidence. 03/01 2007;2007:0505.

Jeong SH, Kim JS, Shin JW, Kim S, Lee H, Lee AY, . . . Ghim Y. Decreased serum vitamin D in idiopathic benign paroxysmal positional vertigo. J Neurol. Mar 2013;260(3):832-838.

Johns Hopkins Medicine. Neurology and Neurosurgery. Vestibular Migraine. http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/conditions/vestibular_migraine.html. Accessed 4/22/2016.

Johnston CS, Meyer CG, Srilakshmi JC. Vitamin C elevates red blood cell glutathione in healthy adults. The American journal of clinical nutrition. July 1, 1993 1993;58(1):103-105.

Kartal AG, Yilmaz S, Yaka E, Pekdemir M, Sarisoy HT, Cekmen MB, Yuksel M. Diagnostic value of S100B protein in the differential diagnosis of acute vertigo in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Jul 2014;21(7):736-741.

Kayabasi S, Iriz A, Cayonu M, Cengiz B, Acar A, Boynuegri S, . . . Eryilmaz A. Vestibular functions were found to be impaired in patients with moderate-to-severe obstructive sleep apnea. The Laryngoscope. May 2015;125(5):1244-1248.

Kent KD, Harper WJ, Bomser JA. Effect of whey protein isolate on intracellular glutathione and oxidant-induced cell death in human prostate epithelial cells. Toxicology in vitro: an international journal published in association with BIBRA. Feb 2003;17(1):27-33.

Kerber KA. Vertigo and Dizziness in the Emergency Department. Emergency medicine clinics of North America. 2009a;27(1):39-viii.

Kerber KA. Vertigo and dizziness in the emergency department. Emergency medicine clinics of North America. Feb 2009b;27(1):39-50, viii.

Ketola S, Havia M, Appelberg B, Kentala E. Psychiatric symptoms in vertiginous patients. Nordic journal of psychiatry. May 2015;69(4):287-291.

Kim BW, Koppula S, Kim JW, Lim HW, Hwang JW, Kim IS, . . . Choi DK. Modulation of LPS-stimulated neuroinflammation in BV-2 microglia by Gastrodia elata: 4-hydroxybenzyl alcohol is the bioactive candidate. Journal of ethnopharmacology. Jan 31 2012;139(2):549-557.

Kim HA, Yi HA, Lee H. Recent advances in orthostatic hypotension presenting orthostatic dizziness or vertigo. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. Nov 2015;36(11):1995-2002.

Kirtane MV, Medikeri SB, Rao P. Blood levels of glucose and insulin in Meniere's disease. Acta oto-laryngologica. Supplementum. 1984;406:42-45.

Klopp R, Niemer W, Weiser M. Microcirculatory effects of a homeopathic preparation in patients with mild vertigo: an intravital microscopic study. Microvascular research. Jan 2005;69(1-2):10-16.

Kolte D, Vijayaraghavan K, Khera S, Sica DA, Frishman WH. Role of magnesium in cardiovascular diseases. Cardiology in review. Jul-Aug 2014;22(4):182-192.

Kornilova LN, Temnikova VV, Naumov IA, Ekimovskii GA, Solov'eva AD. [Computer-aided techniques for the treatment and rehabilitation of patients suffering vertigo and balance disorders]. Vestnik otorinolaringologii. 2010(6):38-43.

Kraft JR. Hyperinsulinemia: A Merging History with Idiopathic Tinnitus, Vertigo, and Hearing Loss. The international tinnitus journal. 1998;4(2):127-130.

Kumar A, Kaur H, Devi P, Mohan V. Role of coenzyme Q10 (CoQ10) in cardiac disease, hypertension and Meniere-like syndrome. Pharmacology & therapeutics. Dec 2009;124(3):259-268.

Lahmann C, Henningsen P, Brandt T, Strupp M, Jahn K, Dieterich M, . . . Schmid G. Psychiatric comorbidity and psychosocial impairment among patients with vertigo and dizziness. Journal of neurology, neurosurgery, and psychiatry. Mar 2015;86(3):302-308.

Lazzini S, Polinelli W, Riva A, Morazzoni P, Bombardelli E. The effect of ginger (Zingiber officinalis) and artichoke (Cynara cardunculus) extract supplementation on gastric motility: a pilot randomized study in healthy volunteers. European review for medical and pharmacological sciences. Jan 2016;20(1):146-149.

Leclercq C, Molinaro MG, Piccinelli R, Baldini M, Arcella D, Stacchini P. Dietary intake exposure to sulphites in Italy--analytical determination of sulphite-containing foods and their combination into standard meals for adults and children. Food additives and contaminants. Dec 2000;17(12):979-989.

Lehrer JF, Poole DC, Seaman M, Restivo D, Hartman K. Identification and treatment of metabolic abnormalities in patients with vertigo. Archives of internal medicine. Aug 1986;146(8):1497-1500.

Lepcha A, Amalanathan S, Augustine AM, Tyagi AK, Balraj A. Flunarizine in the prophylaxis of migrainous vertigo: a randomized controlled trial. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. Nov 2014;271(11):2931-2936.

Li HB, Chen F. Preparative isolation and purification of gastrodin from the Chinese medicinal plant Gastrodia elata by high-speed counter-current chromatography. Journal of chromatography. A. Oct 15 2004;1052(1-2):229-232.

Li JP, Cai J, Gan XM. [Observation of therapeutic effects on cervical vertigo treated with different methods]. Zhongguo zhen jiu = Chinese acupuncture & moxibustion. May 2011;31(5):405-408.

Lin E, Aligene K. Pharmacology of balance and dizziness. NeuroRehabilitation. 2013;32(3):529-542.

Luchikhin LA, Ganichkina I, Doronina OM. [Biological feedback techniques in rehabilitation of patients with impaired equilibrium function]. Vestnik otorinolaringologii. 2002(2):18-20.

Lynch JR, Blessing R, White WD, Grocott HP, Newman MF, Laskowitz DT. Novel diagnostic test for acute stroke. Stroke; a journal of cerebral circulation. Jan 2004;35(1):57-63.

Mahajan SK, Aundhakar SC. A study of the prevalence of serum vitamin B12 and folic Acid deficiency in Western maharashtra. Journal of family medicine and primary care. Jan-Mar 2015;4(1):64-68.

Mangabeira Albernaz PL, Fukuda Y. Glucose, insulin and inner ear pathology. Acta oto-laryngologica. May-Jun 1984;97(5-6):496-501.

Marx W, Ried K, McCarthy AL, Vitetta L, Sali A, McKavanagh D, Isenring E. Ginger-Mechanism of Action in Chemotherapy-induced Nausea and Vomiting: A Review. Critical reviews in food science and nutrition. Apr 7 2015:0.

Mayo Clinic. Diseases and Conditions: Benign Paroxysmal Positional Vertigo. Available at http://www.mayoclinic.org/diseases-conditions/vertigo/basics/lifestyle-home-remedies/con-20028216?p=1. Last updated 05/28/2015. Accessed 10/22/2015.

McCormack PL, Wagstaff AJ. Lacidipine: a review of its use in the management of hypertension. Drugs. 2003;63(21):2327-2356.

Mercier E, Boutin A, Lauzier F, Fergusson DA, Simard JF, Zarychanski R, . . . Turgeon AF. Predictive value of S-100beta protein for prognosis in patients with moderate and severe traumatic brain injury: systematic review and meta-analysis. BMJ (Clinical research ed.). 2013;346:f1757.

Middleton N, Jelen P, Bell G. Whole blood and mononuclear cell glutathione response to dietary whey protein supplementation in sedentary and trained male human subjects. International journal of food sciences and nutrition. Mar 2004;55(2):131-141.

Mikulec AA, Kowalczyk KA, Pfitzinger ME, Harris DA, Jackson LE. Negative association between treated osteoporosis and benign paroxysmal positional vertigo in women. The Journal of laryngology and otology. Apr 2010;124(4):374-376.

Millichap JG, Yee MM. The diet factor in pediatric and adolescent migraine. Pediatric neurology. Jan 2003;28(1):9-15.

Morawiec-Bajda A, Lukomski M, Latkowski B. The clinical efficacy of Vertigoheel in the treatment of vertigo of various etiology. Panminerva medica. Jun 1993;35(2):101-104.

Mraz M, Curzytek M, Mraz MA, Gawron W, Czerwosz L, Skolimowski T. Body balance in patients with systemic vertigo after rehabilitation exercise. Journal of physiology and pharmacology : an official journal of the Polish Physiological Society. Nov 2007;58 Suppl 5(Pt 1):427-436.

Murofushi T. Clinical application of vestibular evoked myogenic potential (VEMP). Auris, nasus, larynx. Jan 11 2016.

Murofushi T, Nakahara H, Yoshimura E, Tsuda Y. Association of air-conducted sound oVEMP findings with cVEMP and caloric test findings in patients with unilateral peripheral vestibular disorders. Acta oto-laryngologica. Sep 2011;131(9):945-950.

Nadeau DA. Management of type 2 diabetes mellitus in self-motivated patients: optimized diet, exercise, and medication for weight loss and cardiometabolic fitness. The Physician and sportsmedicine. Nov 2014;42(4):49-59.

Nakayama M, Masuda A, Ando KB, Arima S, Kabaya K, Inagaki A, . . . Murakami S. A Pilot Study on the Efficacy of Continuous Positive Airway Pressure on the Manifestations of Meniere's Disease in Patients with Concomitant Obstructive Sleep Apnea Syndrome. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. Oct 2015;11(10):1101-1107.

Naprienko MV. [Tanakan in the treatment of cognitive and autonomic impairments and headache in young patients]. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova / Ministerstvo zdravookhraneniia i meditsinskoi promyshlennosti Rossiiskoi Federatsii, Vserossiiskoe obshchestvo nevrologov [i] Vserossiiskoe obshchestvo psikhiat. 2014;114(6):38-41.

Neuhauser HK, Lempert T. Vertigo: epidemiologic aspects. Seminars in neurology. Nov 2009;29(5):473-481.

NICE. National Institute for Health and Care Excellence. Migraine prophylaxis: flunarizine. https://www.nice.org.uk/advice/esuom33/chapter/key-points-from-the-evidence. Copyright 2016. Accessed 1/21/2016.

NIDCD. National Institute on Deafness and Other Communcation Disorders. Otosclerosis. http://www.nidcd.nih.gov/health/hearing/Pages/otosclerosis.aspx#4. Last updated 9/2013. Accessed 2/3/2016.

NIH. National Institutes of Health/US National Library of Medicine. Medline-Plus: Medical Encyclopedia: Vertigo-Associated Disorders. Available at https://www.nlm.nih.gov/medlineplus/ency/article/001432.htm. Last updated 10/21/2015. Accessed 10/22/2015.

Obermann M, Strupp M. Current treatment options in vestibular migraine. Frontiers in neurology. 2014;5:257.

Olszewski J, Repetowski M, Kusmierczyk K. [Comparative assessment of results in cervical vertigo pharmacotherapy vs physiotherapy treatment]. Otolaryngologia polska. The Polish otolaryngology. 2007;61(5):827-830.

Orendorz-Fraczkowska K, Pospiech L, Gawron W. [Results of combined treatment for vestibular receptor impairment with physical therapy and Ginkgo biloba extract (Egb 761)]. Otolaryngologia polska. The Polish otolaryngology. 2002;56(1):83-88.

Osterloh IH. An update on the safety of amlodipine. Journal of cardiovascular pharmacology. 1991;17 Suppl 1:S65-68.

Park JJ, Shen A, Keil S, Kuhl C, Westhofen M. Jugular bulb abnormalities in patients with Meniere's disease using high-resolution computed tomography. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. Aug 2015;272(8):1879-1884.

Peikert A, Wilimzig C, Kohne-Volland R. Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia : an international journal of headache. Jun 1996;16(4):257-263.

Peluso ET, Quintana MI, Gananca FF. Anxiety and depressive disorders in elderly with chronic dizziness of vestibular origin. Brazilian journal of otorhinolaryngology. Oct 9 2015.

Perez N, Santandreu E, Benitez J, Rey-Martinez J. Improvement of postural control in patients with peripheral vestibulopathy. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. May 2006;263(5):414-420.

Post RE, Dickerson LM. Dizziness: a diagnostic approach. American family physician. Aug 15 2010;82(4):361-368, 369.

Purrucker JC, Herrmann O, Lutsch JK, Zorn M, Schwaninger M, Bruckner T, . . . Veltkamp R. Serum protein S100beta is a diagnostic biomarker for distinguishing posterior circulation stroke from vertigo of nonvascular causes. European neurology. 2014;72(5-6):278-284.

Ramachandran U, Manavalan A, Sundaramurthi H, Sze SK, Feng ZW, Hu JM, Heese K. Tianma modulates proteins with various neuro-regenerative modalities in differentiated human neuronal SH-SY5Y cells. Neurochemistry international. Jun 2012;60(8):827-836.

Rauch SD. Clinical hints and precipitating factors in patients suffering from Meniere's disease. Otolaryngologic clinics of North America. Oct 2010;43(5):1011-1017.

Rosengren SM, Kingma H. New perspectives on vestibular evoked myogenic potentials. Current opinion in neurology. Feb 2013;26(1):74-80.

Samuels MA, Pomerantz BJ, Sadow PM. Case records of the Massachusetts General Hospital. Case 14-2010. A 54-year-old woman with dizziness and falls. The New England journal of medicine. May 13 2010;362(19):1815-1823.

Schneider B, Klein P, Weiser M. Treatment of vertigo with a homeopathic complex remedy compared with usual treatments: a meta-analysis of clinical trials. Arzneimittel-Forschung. 2005;55(1):23-29.

Schroeter ML, Sacher J, Steiner J, Schoenknecht P, Mueller K. Serum S100B represents a new biomarker for mood disorders. Current drug targets. Oct 2013;14(11):1237-1248.

Schultz AR, Neves-Souza RD, Costa Vde S, Meneses-Barriviera CL, Franco PP, Marchiori LL. Is There a Possible Association between Dietary Habits and Benign Paroxysmal Positional Vertigo in the Elderly? The Importance of Diet and Counseling. International archives of otorhinolaryngology. Oct 2015;19(4):293-297.

Sennaroglu L, Sennaroglu G, Gursel B, Dini FM. Intratympanic dexamethasone, intratympanic gentamicin, and endolymphatic sac surgery for intractable vertigo in Meniere's disease. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. Nov 2001;125(5):537-543.

Serra AP, Lopes KdC, Dorigueto RS, Ganança FF. Blood glucose and insulin levels in patients with peripheral vestibular disease. Brazilian journal of otorhinolaryngology. 2009;75(5):701-705.

Shamliyan TA, kane RL, Ramakrishnan R, Taylor FR. Migraine in Children: Preventive Pharmacologic Treatments [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US): 2013 Jun. (Comparative Effectiveness Reviews, No. 108). Executive Summary. http://www.ncbi.nlm.nih.gov/books/NBK148703/. Accessed 2/18/2016.

Shutty MS, Jr., Dawdy L, McMahon M, Buckelew SP. Behavioral treatment of dizziness secondary to benign positional vertigo following head trauma. Archives of physical medicine and rehabilitation. Jun 1991;72(7):473-476.

Singh B, Arora S. Acute presentation of dizziness in vitamin B12 deficient old patient of cardiac disease: a case report. Clinica chimica acta; international journal of clinical chemistry. Dec 14 2010;411(23-24):2104-2106.

Sismanis A. Surgical management of common peripheral vestibular diseases. Current opinion in otolaryngology & head and neck surgery. Oct 2010;18(5):431-435.

Sokolova L, Hoerr R, Mishchenko T. Treatment of Vertigo: A Randomized, Double-Blind Trial Comparing Efficacy and Safety of Ginkgo biloba Extract EGb 761 and Betahistine. International journal of otolaryngology. 2014;2014:682439.

Someya S, Xu J, Kondo K, Ding D, Salvi RJ, Yamasoba T, . . . Prolla TA. Age-related hearing loss in C57BL/6J mice is mediated by Bak-dependent mitochondrial apoptosis. Proceedings of the National Academy of Sciences of the United States of America. Nov 17 2009;106(46):19432-19437.

Sowerby LJ, Rotenberg B, Brine M, George CF, Parnes LS. Sleep apnea, daytime somnolence, and idiopathic dizziness--a novel association. The Laryngoscope. Jun 2010;120(6):1274-1278.

Span P. The New York Times [online]. Health page. An Easy Fix for Vertigo. http://www.nytimes.com/2016/03/01/science/an-easy-fix-for-vertigo.html?_r=1. 2/26/2016. Accessed 4/22/2016.

Steinberger A, Pansini M. The treatment of Meniere's disease by acupuncture. The American journal of Chinese medicine. 1983;11(1-4):102-105.

Strupp M, Brandt T. Diagnosis and treatment of vertigo and dizziness. Deutsches Arzteblatt international. Mar 2008;105(10):173-180.

Strupp M, Dieterich M, Brandt T. The treatment and natural course of peripheral and central vertigo. Deutsches Arzteblatt international. Jul 2013;110(29-30):505-515; quiz 515-506.

Sun-Edelstein C, Mauskop A. Foods and supplements in the management of migraine headaches. The Clinical journal of pain. Jun 2009;25(5):446-452.

Susanto M. Dizziness: if not vertigo could it be cardiac disease? Australian family physician. May 2014;43(5):264-269.

Syed I, Aldren C. Meniere's disease: an evidence based approach to assessment and management. International journal of clinical practice. Feb 2012;66(2):166-170.

Takumida M, Anniko M, Ohtani M. Radical scavengers for Meniere's disease after failure of conventional therapy: a pilot study. Acta oto-laryngologica. Aug 2003;123(6):697-703.

Talaat HS, Abuhadied G, Talaat AS, Abdelaal MS. Low bone mineral density and vitamin D deficiency in patients with benign positional paroxysmal vertigo. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. Sep 2015;272(9):2249-2253.

Talaat HS, Kabel AH, Khaliel LH, Abuhadied G, El-Naga HA, Talaat AS. Reduction of recurrence rate of benign paroxysmal positional vertigo by treatment of severe vitamin D deficiency. Auris, nasus, larynx. Sep 16 2015.

Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. Jun 14 2011;183(9):E571-592.

Thompson TL, Amedee R. Vertigo: a review of common peripheral and central vestibular disorders. The Ochsner journal. Spring 2009;9(1):20-26.

Torshin I, Gromova OA, Kalacheva AG, Oshchepkova EV, Martynov AI. [Meta-analysis of clinical trials of cardiovascular effects of magnesium orotate]. Terapevticheskii arkhiv. 2015;87(6):88-97.

UMMC. University of Maryland Medical Center. Ginkgo biloba. Available at: http://umm.edu/health/medical/altmed/herb/ginkgo-biloba. Last updated 5/7/13a. Accessed 9/8/14.

UMMC. University of Maryland Medical Center. Health Information: Medical Reference Guide: Complementary and Alternative Medicine Guide: Treatment: Relaxation techniques. Available at https://umm.edu/health/medical/altmed/treatment/relaxation-techniques. Last updated 09/24/2013b. Accessed 11/23/2015.

Vanni S, Pecci R, Casati C, Moroni F, Risso M, Ottaviani M, . . . Vannucchi P. STANDING, a four-step bedside algorithm for differential diagnosis of acute vertigo in the Emergency Department. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale. Dec 2014;34(6):419-426.

VDA. Vestibular Disorders Association. About Vestibular Disorders page. Medication: Can Medication Help Me Feel Better? http://vestibular.org/understanding-vestibular-disorders/treatment/vestibular-medication. Copyright 2016a. Accessed 2/23/2016.

VDA. Vestibular Disorders Association. Educational Resources page. Labyrinthitis and Vestibular Neuritis: Infections of the Inner Ear. http://vestibular.org/labyrinthitis-and-vestibular-neuritis. Copyright 2016b. Accessed 2/18/2016.

VDA. Vestibular Disorders Association. Educational Resources page. Vestibular Migraine (a.k.a. Migraine Associated Vertigo or MAV). http://vestibular.org/migraine-associated-vertigo-mav. Copyright 2016c. Accessed 3/14/2016.

Venhovens J, Meulstee J, Verhagen WI. Vestibular evoked myogenic potentials (VEMPs) in central neurological disorders. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology. Jan 2016;127(1):40-49.

von Brevern M. Acute dizziness and vertigo: The bedside testing is essential. Journal of neurosciences in rural practice. Apr-Jun 2015;6(2):133-134.

Webster G, Sens PM, Salmito MC, Cavalcante JD, Santos PR, Silva AL, Souza EC. Hyperinsulinemia and hyperglycemia: risk factors for recurrence of benign paroxysmal positional vertigo. Brazilian journal of otorhinolaryngology. Jul-Aug 2015;81(4):347-351.

Weinreich HM, Agrawal Y. The link between allergy and Meniere's disease. Current opinion in otolaryngology & head and neck surgery. Jun 2014;22(3):227-230.

Wetmore S. First Consult. Evaluation and initial management of vertigo. www.clinicalkey.com. Copyright Elsevier BV, Inc. Last updated 8/11/2013. Accessed 11/2/2015.

Wipperman J. Dizziness and vertigo. Primary care. Mar 2014;41(1):115-131.

Xu L LZ, Cheng F, et al Clinical Curative Effect Exploration on the Treatment of Emergency Vertigo by Gastrodine combined with Promethazine. Available at http://en.cnki.com.cn/Article_en/CJFDTOTAL-ZSSA201311011.htm#. Accessed 12/05/2015. 2013.

Yamanaka T, Shirota S, Sawai Y, Murai T, Fujita N, Hosoi H. Osteoporosis as a risk factor for the recurrence of benign paroxysmal positional vertigo. The Laryngoscope. Nov 2013;123(11):2813-2816.

Yang YK, Wang LP, Chen L, Yao XP, Yang KQ, Gao LG, Zhou XL. Coenzyme Q10 treatment of cardiovascular disorders of ageing including heart failure, hypertension and endothelial dysfunction. Clinica chimica acta; international journal of clinical chemistry. Aug 6 2015;450:83-89.

Yardan T, Erenler AK, Baydin A, Aydin K, Cokluk C. Usefulness of S100B protein in neurological disorders. J Pak Med Assoc. Mar 2011;61(3):276-281.

Ye C, Jiang S, Fang J, et al. Meta-Analysis of Gastrodin Injection in the Treatment of Vertigo. Available at http://en.cnki.com.cn/Article_en/CJFDTotal-ZGUD200922035.htm. Accessed 12/05/2015. 2009.

Young YH. Potential application of ocular and cervical vestibular-evoked myogenic potentials in Meniere's disease: a review. The Laryngoscope. Feb 2013;123(2):484-491.

Yu S, Liu F, Cheng Z, Wang Q. Association between osteoporosis and benign paroxysmal positional vertigo: a systematic review. BMC neurology. 2014;14:110.

Zanchetti A, Parati G, Malacco E. Zofenopril plus hydrochlorothiazide: Combination therapy for the treatment of mild to moderate hypertension. Drugs. 2006;66(8):1107-1115.