Vertigo and Dizziness

Vertigo and Dizziness

Last updated: 03/2021

Contributor(s): Dr. Maureen Williams, ND; Dr. Shayna Sandhaus, PhD

1 Overview

Summary and Quick Facts

  • Vertigo is an unpleasant sensation of spinning, dizziness, or motion that can be quite debilitating. It is more common in older adults and typically arises from problems in the inner ear structures or central nervous system.
  • With no treatment, over 60% of patients with the most common type of vertigo (caused by debris in the inner ear) recover within four weeks.
  • This protocol summarizes the types and causes of dizziness and vertigo and the different treatment strategies available, including repositioning techniques to remove debris from the inner ear either at home or at the doctor’s office.
  • Evidence has been reported for the benefit of vitamin D and calcium supplementation in patients with low vitamin D levels and benign paroxysmal positional vertigo (BPPV).

Vertigo, typically characterized by a sensation of spinning or dizziness, is usually caused by problems involving the inner ear (peripheral vertigo) or, less commonly, the central nervous system (central vertigo). Seeking medical attention quickly for sudden unexplained vertigo is essential, as stroke is an uncommon but life-threatening cause of vertigo.

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

Some types of vertigo and dizziness are associated with abnormal glucose metabolism, osteoporosis, sleep apnea, and menopause and hormone fluctuations.

The primary treatment for the most common type of vertigo, caused by debris in the inner ear, is repositioning therapy, which can relieve vertigo in a single session when performed by a trained clinician. At-home repositioning techniques may also improve vertigo.

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

What are Vertigo Causes and Risk Factors?

  • Debris in the inner ear causes benign paroxysmal positional vertigo (BPPV), the most common type of vertigo, which accounts for between 17% and 42% of cases.
  • Another potential cause of vertigo is Ménière disease, a rare but serious condition associated with progressive episodes of vertigo, hearing loss, and tinnitus (ringing in the ears).
  • Migraine sufferers have an elevated risk of developing vertigo, as do older people, women, and people with a family history of the condition.
  • Several comorbid conditions increase the risk of vertigo, including diabetes and abnormal glucose metabolism, osteoporosis, high cholesterol, and depression and anxiety.
  • Many medications can cause dizziness or vertigo, including some antibiotics, statins, and antidepressants. If a new medication was initiated soon before to the onset of vertigo, it should be more closely scrutinized as a possible factor contributing to symptoms.

How is the Cause of Vertigo Diagnosed?

  • Physicians must rule out urgent causes of vertigo and dizziness, such as stroke.
  • Several vertigo diagnostic algorithms are available, with most depending on the timing, triggers, and duration of vertigo episodes.
  • A physical examination that evaluates for 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 BPPV.
  • Emerging findings suggest serum protein S100-beta, a novel diagnostic biomarker, may be useful in differentiating vertigo caused by vascular stroke.
  • Generally, laboratory evaluation and imaging are not necessary to identify the cause of vertigo.

How is Vertigo Treated?

  • Manual manipulation techniques, including the Semont and Epley maneuvers, are designed to move debris out of the semicircular canals in the inner ear and are effective in the majority of cases of BPPV.
  • The half-somersault maneuver to move crystals out of the semicircular canals is a technique developed for at-home use without assistance.
  • Diuretic medications are commonly used to treat Ménière disease, but some evidence suggests medication may not be effective.

What Novel and Emerging Strategies May Benefit Those with Vertigo?

  • Flunarizine, a calcium channel blocker drug used for migraines in Europe but not approved in the United States, has shown promise as a potential treatment for migraine-associated vertigo. Another calcium channel blocker and antiemetic, cinnarizine, is being explored as a potential vertigo therapy as well. Neither drug is available in the United States as of early 2021.
  • Piracetam, a derivative of the neurotransmitter gamma-aminobutyric acid (GABA), has been investigated as a treatment option for Ménière disease.
  • Biofeedback techniques incorporated into vestibular rehabilitation programs have appeared promising as well.

What Dietary and Lifestyle Considerations May Benefit Those with Vertigo?

  • Follow a consistent low-sodium diet for Ménière disease.
  • Avoid migraine trigger foods (including red wine, cheese, and chocolate) if vertigo is experienced with migraines.
  • Stress reduction may be helpful.

What Nutrients Can Benefit Vertigo?

  • Vitamin D: Vitamin D supplementation may 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 related to Ménière disease.
  • Ginger root: Some studies suggest ginger may help relieve vertigo and associated symptoms, such as nausea.
  • Coenzyme Q10 (CoQ10): Patients with congestive heart failure were treated with CoQ10 and 73% of patients with vertigo reported improvement in their vertigo.

2 Introduction

Vertigo is the perception of movement while not in motion; it typically manifests as a sensation of spinning, swaying, or tilting. Vertigo may be perceived as motion of oneself or one’s environment. It may be accompanied by nausea and vomiting or a lack of physical steadiness or equilibrium.1 Vertigo is a symptom, not a diagnosis. It is usually caused by problems in the inner ear or central nervous system.1,2 Importantly, vertigo can be a symptom of a serious condition, such as stroke. Seeking medical attention quickly for sudden, unexplained vertigo is essential.3

Although many people assume that “vertigo” and “dizziness” are synonymous, 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). In addition to vertigo, several other types of dizziness have been identified and can be loosely characterized by how they are perceived: presyncope (fainting sensation), disequilibrium (imbalance sensation), and lightheadedness (feeling faint or about to pass out).2,4,5 Both vertigo and dizziness have underlying causes that must be identified and addressed.6-9

Up to 20% of the population may experience at least one episode of dizziness or vertigo per year.10,11 The prevalence increases with age: about half of people over age 85 years experience periodic vertigo or dizziness.12 Vertigo can interfere with one’s ability to work and live independently, reducing quality of life.13 Vertigo is a common cause of falls among older individuals, and falls are a leading cause of accidental death in seniors.12,14,15 For patients with recurrent vertigo or with functional or quality of life limitations due to vertigo symptoms, treatment will vary with the cause, but may include nonpharmacologic, pharmacologic, and/or integrative interventions.16-22

The most common type of vertigo, benign paroxysmal positional vertigo, or BPPV, accounts for between 17% and 42% of vertigo cases.15,16 BPPV is most commonly caused by displaced particles of calcium debris (called canaliths) in the small canals of the inner ear.1 These canals are important parts of the body’s equilibration system. Most cases of BPPV resolve within four weeks, even without treatment.23 BPPV can often be treated with maneuvers intended to move the particles out of the canals (known as repositioning). The canalith repositioning maneuver (also called the Epley maneuver) is performed by a clinician and can rapidly resolve many cases of vertigo.16 Additionally, some unassisted movement techniques, including the half-somersault maneuver, can be used to self-treat vertigo at home in some cases.24-26

Other causes of vertigo, such as vestibular migraine and Ménière disease, may respond to medication.17,18 Some emerging interventions, such as correction of jugular vein abnormalities and biofeedback therapy, continue to undergo research in the context of vertigo.19-22

Several chronic conditions have been linked with vertigo or dizziness, including anxiety,27 diabetes,28-32 osteoporosis,33,34 migraine,35-38 and sleep apnea.35-38 Therefore, appropriate management includes treatment of chronic predisposing conditions.39 Several natural agents such as vitamin D, calcium, ginkgo biloba, and coenzyme Q10 may be effective adjuvants in the management of vertigo.40-42 Depending on the cause of vertigo, some dietary and lifestyle considerations, such as a low-sodium diet, may reduce the severity or frequency of symptoms as well.

3 Background

Figure 1. Anatomy of the inner ear.
Figure 1. Anatomy of the inner ear.

Vertigo can result from disturbances of either the vestibular structures of the inner ear, which sense linear and angular motion, or the regions of the central nervous system that transmit and process signals from the vestibular organs. The key vestibular organs implicated in vertigo are the semicircular canals or ducts, as well as the utricle and saccule, which are often referred to as the otolith organs (Figure 1).43 The brain receives signals from both the right and left inner ears via the vestibulocochlear nerve (also called the eighth cranial nerve [CN VIII]). During movement, differences in nerve signaling from the right and left ears are interpreted as motion. When individuals experience vertigo, asymmetric right-left signaling resulting from inner ear problems or central nervous system issues results in an abnormal sensation of motion.1,44

Vertigo has been classically separated into two main categories: peripheral and central. While there is some overlap between peripheral and central causes of vertigo, peripheral vertigo primarily arises from problems in the vestibular apparatus of the inner ear or the vestibular nerve. Central vertigo arises from problems in the cerebellum or brainstem where signals from the vestibular system are received and interpreted.1,44 The majority—roughly 80%—of cases of vertigo are of the peripheral type.1

Depending on the underlying condition, vertigo and dizziness can present in a variety of ways (see Table 1). Typically, episodes of vertigo can be characterized by their timing, triggers, and associated symptoms.2 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 presyncope due to hypotension.8

“Vertigo” versus “Dizziness”—What Is the Difference?

The terms “vertigo” and “dizziness” are frequently used interchangeably, though inaccurately, to refer to the same symptom. However, vertigo and dizziness have specific meanings.8

“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.6

Dizziness typically falls into one of four categories: vertigo, presyncope, disequilibrium, and lightheadedness. Vertigo related to inner-ear or vestibular problems (eg, positional vertigo) is a common cause of dizziness.7,8

4 Causes and Risk Factors

Many factors can contribute to vertigo and dizziness, including 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 outlined in Table 1.

Risk Factors for Vertigo

Risk factors associated with vertigo include:

  • Older age46,47
  • Female gender46,47
  • Menopause and associated hormonal fluctuations48
  • Low levels of vitamin D47
  • Osteoporosis47
  • Migraine headache47
  • Head and neck trauma47
  • High total cholesterol levels47
  • Depression and anxiety49,50
  • Stress51
  • Family history of balance disorders52
Table 1. Common Origins and Manifestations of Vertigo1,53
Disorder
Manifestations
Peripheral Causes of Vertigo
Benign paroxysmal positional vertigo (BPPV)16
  • Recurrent episodes of vertigo often lasting one minute or less and triggered by specific movements of the head
  • Nystagmus (involuntary, rapid, sweeping movement of the eyes) is often present
  • Intermittent course, with patients often restricting movement to prevent episodes
Herpes zoster oticus (Ramsay Hunt syndrome)54
  • Acute onset of vertigo typically lasting multiple days, often gradually resolving in a few days with indicated anti-inflammatory and antiviral therapies
  • May also present with hearing loss, facial paralysis, ear pain, and vesicles in the auditory canal, all on the same side of the body
Ménière disease55
  • Sudden-onset episodes of vertigo lasting from one to 24 hours
  • Episodes often preceded by tinnitus (ringing in the ear), ear pressure or fullness on one side, and unilateral hearing loss
  • May be accompanied by visual disturbances, nausea, and vomiting
Vestibular neuritis (also called vestibular neuronitis or peripheral vestibulopathy) and labyrinthitis56
  • Sudden onset of severe vertigo lasting one to two days before gradually returning to normal over a few weeks
  • Commonly occurs with or subsequent to a viral illness
  • May be accompanied by nausea, vomiting, and gait impairment
  • Rarely recurs
  • In vestibular neuritis, hearing is preserved
  • In labyrinthitis, unilateral hearing loss is present
Central Causes of Vertigo
Brainstem ischemia (insufficient blood flow), including transient ischemic attack57
  • Usually spontaneous vertigo episodes lasting seconds to hours
  • Can be difficult to distinguish from peripheral vertigo
  • More common in individuals with vascular risk factors

Stroke and hemorrhage57

  • Spontaneous, severe vertigo
  • Typically accompanied by nausea or vomiting
  • Can be difficult to distinguish from peripheral vertigo (particularly vestibular neuritis)
  • More common in older individuals (>60 years) with risk factors such as hypertension and diabetes
Vestibular migraine58
  • Highly variable duration and intensity of vertigo lasting anywhere from 5 minutes to 72 hours
  • Accompanied by at least one migraine feature (headache, sensitivity to sound or light, and/or visual aura)

Causes of Peripheral Vertigo

Approximately 80% of vertigo cases are due to peripheral causes. The most common cause of vertigo overall is benign paroxysmal positional vertigo (BPPV), often shortened to “positional vertigo.” BPPV usually occurs when debris in the inner ear moves during head movement, triggering brief spells of vertigo.1,16

There are two main types of BPPV: posterior semicircular canal BPPV (also known as posterior canal BPPV) and horizontal semicircular canal BPPV (or horizontal canal BPPV). The vast majority of BPPV is posterior canal BPPV, accounting for 85% to 95% of cases. Posterior canal BPPV is usually attributed to canalithiasis, which occurs when fragmented calcium crystals become lodged in the posterior canal. Horizontal BPPV is also believed to be caused by debris particles; however, less is known about the pathology of this form of BPPV.1,16 In certain atypical cases, BPPV can be caused by abnormalities in the brain or nervous system, but this is rare.26

Another common cause of vestibular vertigo is Ménière disease. The precise underlying cause of Ménière disease is not yet clear. Patients with Ménière disease have changes in their inner ear fluid volume, called endolymphatic hydrops, which is believed to lead to swelling, distortion, and small tears in the membrane of the inner ear. These changes lead to progressive symptoms, with both increasing frequency and severity of vertigo and hearing loss. The cause of endolymphatic hydrops is unclear, and while all patients with Ménière disease have endolymphatic hydrops, not all patients with endolymphatic hydrops have Ménière disease, which has led to the suggestion of an array of possible causes including genetic predisposition, viral infection, and multiple other biochemical and immune factors.18,59

Vestibular neuritis and labyrinthitis are other common causes of vertigo. Vestibular neuritis (inner ear inflammation) is usually caused by an infection of the vestibular branch of the eighth cranial nerve (CN VIII) that transmits signals from the inner ear to the brain.56 Labyrinthitis is an inflammatory, typically infectious, condition of the labyrinth.60

Oxidative Stress and Vertigo

Aging, a risk factor for dizziness and vertigo, is marked by the cumulative effects of oxidative stress.61 A growing body of evidence points to increased oxidative stress as an underlying contributor to both peripheral and central causes of vertigo. Studies in BPPV patients have found they have higher oxidative stress levels and lower levels of sulfur-based antioxidants and superoxide dismutase (SOD, a radical-quenching enzyme) than matched healthy controls.62-64 Levels of the endogenous antioxidant molecules uric acid, bilirubin, albumin, and creatinine were also found to be lower in BPPV patients.65 It is thought free radicals may directly damage components of the vestibular system and may also disrupt calcium metabolism, promoting crystal formation.63 In Ménière disease, high oxidative stress levels and oxidative damage to blood vessels have been noted, possibly contributing to the inability to maintian fluid balance in the inner ear.66 SOD levels have also been noted to be lower in patients with vertigo due to central vascular causes.67 This evidence suggests treatment strategies that reduce oxidative stress may be beneficial in those with various types of vertigo.

Other causes of peripheral vertigo include1,12,68:

  • Herpes zoster oticus (reactivation of the virus that causes chicken pox [a condition known as shingles] with lesions affecting the inner ear)
  • Otitis media (inflammation [usually of infectious origin] of the middle ear)
  • Medication side effects and interactions (see Table 2)
  • Concussion with trauma to peripheral vestibular organs
  • Otosclerosis (hardening of middle ear structures)

Causes of Central Vertigo

Approximately 20% of vertigo cases are due to central causes of which vestibular migraine is one of the most common. Vestibular migraine is defined as the presence of vertigo episodes and other vestibular symptoms caused by migraine.69 This condition is poorly understood even though one epidemiologic study concluded that it occurs in up to 2.7% of the adult U.S. population.69,70 Numerous possible overlapping mechanisms have been proposed for vestibular migraine. One hypothesis is that in some patients, vestibular migraine is a typical migraine aura, which is caused by an abnormal wave of neuronal signaling in the brainstem. Studies have also reported that calcitonin gene-related peptide, which is known to play a role in the development of migraine and serves as a therapeutic migraine target, may signal vestibular receptors.71,72 In addition, an observational study found migraine sufferers in general were at higher risk of developing BPPV,73 and features of migraine may be present during episodes of Ménière disease.74,75

Other causes of central vertigo include1:

  • Cerebrovascular disease, including transient ischemic attack, stroke, or hemorrhage, affecting the medulla or cerebellum
  • Multiple sclerosis
  • Seizure disorder
  • Genetic conditions
  • Disembarkment syndrome (a sense of motion and imbalance following a period of being in passive motion)
Table 2: Medications and Substances That May Cause Peripheral or Central Vertigo or Dizziness76-79
Medication/Substance
Notes
Antibiotics
Cinoxacin, levoxacin, ciprofloxacin, amoxicillin plus clavulanic acid, aminoglycosides, tetracyclines, amikacin, erythromycin, azithromycin, clarithromycin
May be ototoxic (cause damage to or dysfunction of inner ear structures or nerves involved in equilibration); aminoglycosides can cause irreversible ototoxicity
Diuretics
Ethacrynic acid, furosemide, hydrochlorothiazide
Related to postural hypotension (low blood pressure upon standing); some are potentially ototoxic
Antihypertensives
Enalapril, zofenopril, irbesartan, lacidipine, amlodipine, nifedipine, nicardipine
Due to hypotension (low blood pressure)
Anti-inflammatories and Pain Relievers
Aspirin, acetaminophen, acetylsalicylic acid, ibuprofen, celecoxib, diclofenac, dexketoprofen, ketorolac, naproxen
Potentially ototoxic
Dopaminergic/Parkinson Disease Medications
Bromocriptine, levodopa/carbidopa
May worsen hypotension when taken with antihypertensives
Antipsychotics
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
Although these are sometimes used in the treatment of certain types of vertigo they also may have vertigo as a side effect
Platinum-Derived Chemotherapy
Cisplatin, carboplatin, oxaliplatin
A fairly common side effect is irreversible, progressive ototoxicity, with cisplatin being the worst of the three80
Antifungal and Antimalarial Medications
Amphotericin B, fluconazole, itraconazole, flucytosine, chloroquine
May be ototoxic
Oral Contraceptives Some physiological variations associated with oral contraceptive (OC) use (eg, impaired water and electrolyte balance, variations of endolymphatic pH, and impairment of glucose or lipid metabolism) have been hypothesized to contribute to vertigo in some cases.81 However, this appears to be rare and may vary with type of OC drug, as some OC regimens may be associated with improvements in Meniere’s disease symptoms.82 In general, if vertigo occurs in association with OC use, OC drugs should be considered as apossible contributor.
Alcohol May damage the vestibular system
Caffeine Avoidance may be beneficial in Ménière disease and vestibular migraine83
Heavy Metals and Metalloids
Arsenic, lead, mercury

May be ototoxic

Tobacco May cause dizziness, vertigo, and tinnitus
Note: If vertigo onset occurs shortly after initiation of a new medication, the medication as a potential trigger of vertigo should be ruled out by a qualified healthcare provider.

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, headache, fatigue, and other symptoms.84

Many people experience motion sicknesses during passive motion, such as travel by car, train, or boat. The prevalence of motion sickness ranges from 4% among people who travel by car to up to 25% of people who travel by boat, and is more common in those aboard smaller vessels or in inclement weather. Although anyone with a functional vestibular system is theoretically susceptible to motion sickness, several factors appear to influence risk84:

  • Age. Children aged 6 to 12 years are particularly susceptible. Motion sickness rarely occurs in adults over age 50.
  • Sex. Females are more likely to experience motion sickness than males, particularly during pregnancy or menstruation.
  • Race. Individuals with Asian ancestry are more likely to experience motion sickness than those of Caucasian ancestry.
  • Medical history. People with migraine, Ménière disease, and vertigo are more likely to experience motion sickness.
  • Family history. Children of parents with a history of car sickness are twice as likely to get car sickness.

Some medications may help prevent motion sickness symptoms. Oral treatment is less effective because delayed gastric emptying in motion sickness prevents absorption. Commonly used agents include antihistamines (eg, dimenhydrinate [Dramamine]) and anticholinergic drugs like scopolamine (also referred to as hyoscine). Scopolamine is available as a patch or orally, and has been considered one of the most effective medications for motion sickness. A number of other medications have been studied for motion sickness, including the serotonin receptor agonist rizatriptan (Maxalt).85 Unfortunately, some of these medications can cause side effects such as drowsiness and confusion.84

Motion sickness may also be prevented or relieved by behavioral interventions. A number of specific actions, including lying down on one’s back, shutting the eyes, avoiding sitting in the rear of the vehicle, not reading or viewing a video screen while traveling, and looking at the horizon can reduce the severity of motion sickness. Staying adequately hydrated, eating small meals, and avoiding alcohol, caffeine, and smoking before travel may also help. Distractions such as listening to pleasant music may be useful as well. Ginger-flavored lozenges in particular may help because ginger can promote gastric emptying,86,87 which is sometimes delayed in motion sickness.84

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),88 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 disease, has been shown to be associated with abnormalities of glucose and insulin metabolism.29-31 In fact, people with diabetes may have up to a 70% higher risk of a balance disorder,15 and high glucose and insulin levels have been associated with increased risk of BPPV recurrence.32

The inner ear is rich in insulin receptors. Chronically elevated insulin levels may affect inner ear blood flow, disrupting the complex chemical balance of inner ear fluids and resulting in vestibular dysfunction.32 More information is available in Life Extension’s Diabetes and Glucose Control protocol.

Osteoporosis

People with osteoporosis and osteopenia (reduced bone mineral density but less severe than osteoporosis) were found in two case control studies to have about a 1.3-fold higher risk of developing BPPV.89 In one study, women with osteoporosis and BPPV 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.90 In another study, having been treated for osteoporosis was correlated with a lower risk of BPPV in women 51 to 60 years old.91 Numerous studies have found associations between measures of bone metabolism and bone density, vitamin D levels, and BPPV.92-97 Provisional evidence for a causative contribution of vitamin D deficiency to BPPV comes from a clinical trial that treated severe vitamin D deficiency (<10 ng/mL) and found a highly significant 73% reduction in symptom recurrence.98 This relationship has been hypothesized to result from vitamin D–associated calcium channel proteins in the epithelium that play a role in calcium metabolism of the vestibular organ of the inner ear.96

Studies have also shown that the fracture risk is significantly higher in individuals with BPPV.99,100 This highlights the importance of both BPPV and osteoporosis management, given the elevated risk of falls among people with BPPV.101 For more information about bone health see Life Extension’s Osteoporosis protocol.

Menopause and Associated Hormonal Fluctuations

The average age of menopause in the United States is 51 years, and BPPV incidence has been shown to be relatively high among women aged 40 years and older. Researchers have suggested that a complex interplay between changing hormone levels, aging, and calcium crystals in the inner ear may influence BPPV susceptibility, particularly in perimenopausal women.48,102 Of note, menopause has been strongly linked with the development of osteopenia and osteoporosis (primarily due to decling estrogen levels); however, there are other mechanisms by which hormones, particularly estrogen, may contribute to BPPV.102 Low vitamin D levels have also been reported in postmenopausal women with BPPV.103

In one retrospective population study, women who had taken conventional hormone replacement therapy (HRT) for menopausal symptoms had a 99% lower risk of developing BPPV compared with those who did not.104 In this study, the impact of HRT on bone density was not considered. This population study does not indicate that HRT is indicated as a treatment for BPPV, but suggests a correlation exists. For more information about menopausal symptoms and hormone replacement see Life Extension’s Female Hormone Restoration protocol.

Sleep Apnea

The periodic low blood oxygen levels characteristic of sleep apnea may damage the delicate structures of the vestibular system,37,105 which could increase the risk of peripheral vertigo. In one population study, people with sleep apnea were found to have about 1.7-fold higher risk of experiencing vertigo than those without sleep apnea.38 In another study, people with sleep apnea were found to have higher rates of vestibular migraine, Ménière disease, and hearing loss than the general population.106 Furthermore, patients with more severe obstructive sleep apnea were found to have higher levels of dizziness-related disability than those with mild sleep apnea.37 Patients with sleep apnea and Ménière disease experienced a reduction in Ménière disease symptoms, including dizziness, when their sleep apnea was treated with a continuous positive airway pressure (CPAP) device.36 Refer to Life Extension’s Sleep Apnea protocol for more information.

Depression and Other Mental Health Concerns

There is a high prevalence of anxiety, depression, and other emotional, psychiatric, and cognitive disorders in people with vertigo.107-110 In one study of patients with BPPV, 39% had anxiety or depression, and 28% had a personality disorder.111 One study found canalith repositioning treatment in BPPV was less likely to work in people with anxiety and depression, and the likelihood for recurrence was higher.112 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 a role in psychiatric and cognitive disorders, even in the absence of vertigo.113 For more information, refer to Life Extension’s protocols on anxiety and depression.

6 Diagnosis

Differential Diagnosis

The most urgent diagnostic priority in patients who present with vertigo and dizziness is ruling out urgent causes, such as stroke.3,57,114 Other neurologic signs and symptoms can be clues that a stroke has occurred, such as numbness or weakness of a limb or face, difficulty swallowing, or speech or language difficulties, but sometimes dizziness or vertigo is the only symptom. Therefore, a thorough evaluation may be undertaken.57

Once urgent causes are ruled out, the next step in diagnosis involves ruling out the most common causes. In general, about 40% of patients with dizziness have peripheral vestibular dysfunction, 10% have central brainstem vestibular lesions, 15% have psychiatric disorders, and 25% have other problems such as presyncope and disequilibrium; in the remaining 10%, the cause is unknown.115

Physical Examination

Clinicians may be able to rule out certain causes of dizziness by observing the presence and pattern of nystagmus (involuntary, rapid eye movements) or other eye movement abnormalities.8 Nystagmus is usually evaluated by slowly moving an object and asking the patient to follow it with their gaze, but not their head. Tests involving movements of the head or covering and uncovering each eye may be used to discern the pattern of nystagmus or other abnormal eye movements.116

BPPV can be diagnosed with a specialized maneuver called the Dix-Hallpike test. A clinician performs this test by assisting the patient in rapidly rotating their head while moving from a seated to lying position. If the maneuver recreates vertigo (with or without nystagmus), it points to BPPV as the cause. However, a negative result does not rule out BPPV.16,116

Blood pressure and heart rate in the standing and sitting positions can be measured to diagnose orthostatic hypotension (the inability to maintain normal blood pressure upon rising from a seated or lying position).116 Balance, gait, and neurologic signs also help a clinician determine whether the vertigo is of peripheral or central origin.2

Other Testing

Blood tests may be ordered to help identify possible causes of dizziness and vertigo such as anemia, infection, and thyroid or autoimmune disease, and hearing tests may be used to detect problems related to the inner ear, or the cranial nerve or brain region involved in hearing. A doctor may order imaging tests such as magnetic resonance imaging (MRI) and computed tomography (CT) scans if central causes are suspected.116

Emerging Diagnostic Strategies

Serum protein S100-beta is a novel diagnostic biomarker of neurological injury, and blood levels may be useful in distinguishing neurological origins from other possible causes.117 Recent findings suggest this protein may someday be used in acute care settings to differentiate vertigo caused by stroke from vertigo due to other causes.118-120

Vestibular evoked myogenic potentials are electrical signals that can be measured in the neck or eye muscles and may provide valuable diagnostic information about the function of the vestibular system. Tests measuring these electrical signals are gaining popularity and may help refine the diagnosis of vertigo, although variability in the different available methods remains a challenge.121,122

7 Treatment

Treatment of vertigo depends upon the cause.

Benign Paroxysmal Positional Vertigo (BPPV)

With no treatment, over 60% of patients with BPPV recover within four weeks.23 However, episodes of vertigo (especially recurrent vertigo) can substantially undermine quality of life and increase the risk of falls in elderly people.123,124 Therefore, treatment is recommended for people who are experiencing BPPV.

Canalith repositioning procedures, which are designed to move debris out of the semicircular canals, are frequently used to treat positional vertigo.16 The Semont and Epley maneuvers are among the most widely used repositioning procedures and are effective in the majority of cases.125 One trial found that a combination of methods, including these two, resolved 98% of cases of one-sided posterior BPPV.126

At-home repositioning maneuvers provide alternatives for patients who are unable to go into the clinic for treatment. The half-somersault maneuver is a technique developed for at-home use without assistance. The half-somersault maneuver was compared with an at-home version of the Epley maneuver 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.24 A how-to guide for performing the half-somersault maneuver has been developed by Carol Foster, MD, and is available on her website.

BPPV often occurs in combination with additional vestibular abnormalities. In these cases, symptoms can remain even after successful repositioning treatment and movement of the canaliths or debris which were lodged in the posterior or horizontal semicircular canals. A more complete diagnostic workup may then be necessary to identify the causes of lingering symptoms.16

Avoidance of Antihistamines and Benzodiazepines in BPPV

Antihistamines and benzodiazepines, which are vestibular suppressant medications that treat other vestibular disorders, may delay resolution of symptoms in BPPV. Accordingly, the American Academy of Otolaryngology recommends against their routine use to treat this condition.16

Vestibular Migraine

Vestibular migraine is managed with similar treatments used for migraine headaches, although their efficacy for vestibular migraine is not well-studied. Preventive management includes avoiding triggers and using migraine prophylactic medication, which can include69:

  • Beta-blockers
  • Tricyclic antidepressants
  • Anti-seizure medications
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs), particularly when vestibular symptoms predominate (can worsen headaches)
  • Verapamil, when vertigo manifests in the context of migraine aura

For acute attacks of vertigo, the following vestibular suppressants can be considered69:

  • Antihistamines
  • Antiemetics
  • Benzodiazepines

Ménière Disease

Initial therapy in Ménière disease should be dietary and lifestyle adjustments. This includes reduction in salt intake, caffeine, alcohol, and monosodium glutamate (MSG). Environmental and lifestyle triggers should also be addressed, and can include nicotine, stress, and food or environmental allergies.18,59 During Ménière disease attacks, vestibular suppressants (medications that may help attenuate the vertigo and nystagmus associated with vestibular imbalance) such as antihistamines and benzodiazepines can reduce the symptoms of vertigo, while antiemetics also may be needed acutely if nausea and vomiting exist. Anticholinergic drugs (eg, scopolamine, atropine) can also be used to suppress Ménière disease attacks.59 Chronic symptoms can be treated with betahistine (Serc) (a histamine signaling modulator), available as a compounded preparation in the United States, or diuretics. Glucocorticoids such as prednisone are used to treat difficult cases that do not respond adequately to first-line pharmacologic or other treatments. These can be administered orally or directly into the inner ear.18 The American Academy of Otolaryngology recommends inner ear injection of steroids for patients who do not respond to conventional treatment.59

Other Treatment Considerations

Vestibular rehabilitation. Vestibular rehabilitation is an exercise program intended to reduce vertigo and dizziness, instability, and falls. The goal of vestibular rehabilitation is to promote compensation, a process through which other senses, such as vision, are trained to substitute for the vestibular system. Over time, vestibular rehabilitation can encourage the nervous system to adapt to changes in nerve signaling within the balance control network. Vestibular rehabilitation incorporates three types of exercise, which are individualized according to patients’ specific concerns127:

  • Habituation. Reduces dizziness or vertigo caused by self-motion or visual stimuli
  • Gaze stabilization. Improves control of eye movements to maintain stable vision during movement of the head
  • Balance training. Improves steadiness to facilitate daily activities, such as self-care, work, and recreation

Surgery. Surgery is available as a last resort to treat intractable peripheral vertigo. There are two categories of vestibular surgery: corrective and destructive. Corrective surgery is meant to repair or stabilize inner ear function, whereas destructive surgery’s goal is to stop the inner ear from generating sensory information and transmitting it to the brain. The specific surgical procedure used is individualized based on the patient’s condition.128

8 Novel and Emerging Strategies

Calcium Channel Blockers

Flunarizine (Sibelium) is a calcium channel blocker, and cinnarizine has antihistaminic, antiserotonergic, antidopaminergic, and calcium-channel-blocking activites. They are approved in many countries for migraine prevention (flunarizine) and management of vestibular symptoms and prevention of motion sickness (cinnarizine). As of early 2021, neither medication is approved for any indication in the United States.20,21,129 In a randomized controlled trial, flunarizine was 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 between the two groups in the incidence of the most frequent adverse effects.22

Cinnarizine has been evaluated in combination with other vestibular suppressants. A combination of dimenhydrinate and cinnarizine significantly improved peripheral vestibular vertigo symptoms after four weeks of therapy compared with betahistine alone.130 Similarly, cinnarizine combined with betahistine improved vertigo symptoms over either treatment alone in a clinical trial of 162 patients.131

Piracetam

Piracetam, a derivative of the neurotransmitter gamma-aminobutyric acid (GABA),132 has been investigated as a treatment option for Ménière disease. In a randomized controlled trial of 100 patients with Ménière disease who presented to the emergency department for vertigo, participants received either betahistine (dosed at 8 mg every eight hours) or piracetam (800 mg every eight hours). After seven days of treatment, vertigo recurrence occurred at a similar rate in patients treated with piracetam and betahistine (6% in both groups).133,134 In an open-label observational study in patients with peripheral vestibular vertigo, over 1,600 patients received either piracetam combined with betahistine or betahistine alone. The effect of the combination was superior across multiple indices, including a reduction in dizziness-related functional deficits by 2.3-fold compared with betahistine alone.135

Biofeedback Therapy

Another promising field of research for individuals with chronic or recurrent vertigo of various etiologies is biofeedback therapy. Specific biofeedback techniques can be integrated into vestibular rehabilitation programs. One innovative proposed method is based on the use of computer-generated cues about posture and position that encourage adaptation and improved balance.136 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.137 Similar positive results have been observed in several other studies.138-142

9 Dietary And Lifestyle Considerations

Diet

A low-sodium diet is a commonly used management strategy for Ménière disease, as is avoidance of caffeine, although conclusive evidence from rigorous controlled trials is still lacking for these interventions.59,143 In a survey of patients with Ménière disease, those who followed a low-sodium and caffeine-free diet for more than six months had a greater improvement in vertigo symptoms.144

Certain food additives or constituents may trigger migraines or worsen symptoms of Ménière disease in susceptible individuals. These include nitrates, nitrites, tyramine, aspartame, and monosodium glutamate, as well as caffeine and alcohol.145 Examples of common foods that may provoke symptoms include red wine, beer, chocolate, fermented dairy products including yogurt, and aged or pickled foods. Some practitioners advise patients younger than 50 years who have Ménière disease to eliminate these foods.146 However, no rigorous controlled trials of dietary changes in Ménière disease have been performed,147 and some clinicians have expressed skepticism of the effectiveness of dietary intervention. Nonetheless, if a pattern of Ménière disease episodes can be attributed to certain dietary intakes, it is reasonable and safe to avoid certain foods. More information about dietary migraine triggers, which may be of interest to individuals with Ménière disease, 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.15,148-150

Relaxation Techniques

Individuals suffering from vertigo are more likely to experience depression, anxiety, and/or other psychological conditions.110 Two case reports from one team of authors in Japan reported that autogenic training, a body-mind technique that uses imagery and body awareness to induce a relaxed state, has shown benefit in Ménière disease and psychogenic vertigo.151,152 Relaxation techniques such as mindfulness-based stress reduction, relaxation response training, and cognitive-behavioral stress management have shown therapeutic benefits in managing emotional stress,153 and may prove useful for treating vertigo as well as the psychological issues that may be caused by or contribute to it. Life Extension’s Stress Management protocol describes additional relaxation strategies which may be useful for all sufferers of vertigo as the condition can be stressful for all who experience it.

10 Nutrients

Vitamin D and Calcium

Low vitamin D status has been observed in patients with BPPV, especially in those with chronic recurrent vertigo.154,155 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 among subjects with severe vitamin D deficiency (≤10 ng/mL) the odds of having the condition were dramatically greater than that.156

In a large multicenter randomized controlled trial, 957 patients with BPPV who had received successful treatment with canalith repositioning maneuvers were randomized to ongoing care with a combination of vitamin D and calcium or observation only. Those in the intervention group who were given 400 IU of vitamin D daily along with 500 mg calcium carbonate twice daily for one year had a 24% lower annual risk of BPPV recurrence.41 Similarly, in a meta-analysis of five clinical trials, vitamin D supplementation (as daily or high bolus doses, with or without calcium) was shown to reduce the risk of BPPV recurrence by 63%.157 In a study of 93 participants with BPPV and severe vitamin D deficiency, subjects were given a loading dose of 50,000 IU of vitamin D3 three times weekly for one month, then once every two weeks for two more months. The degree of vertigo improvement over a three-month period following initiation of the vitamin D3 loading dose was correlated with the amount of increase in vitamin D level. In those whose vitamin D status improved by 10 ng/mL or more, only 14% experienced vertigo recurrence. However, in those whose vitamin D level improved by less than 10 ng/mL, 43% experienced an episode of vertigo.98

One study and one meta-analysis failed to find a significant correlation between vitamin D levels and BPPV when comparing patients and controls. However, a subgroup analysis (as part of the meta-anlaysis) found significantly lower vitamin D levels in those with recurring BPPV compared to those with non-recurring disease.158,159

Ginkgo Biloba

Extracts of ginkgo biloba, one of the oldest living species of trees in the world,160 are used in many countries for the treatment for vertigo.161 In a 12-week randomized controlled trial in 160 subjects with peripheral vertigo, 79% of patients who received 120 mg of a ginkgo standardized extract twice daily (providing 22.0–27.0% ginkgo flavonoids and 5.0–7.0% terpene lactones) rated symptoms as “very much improved” or “much improved” from baseline while only 70% of those treated with 16 mg twice daily of the drug betahistine had the same level of improvement.162 Additionally, ginkgo was better tolerated. In an earlier trial in people with vestibular vertigo, 80 mg of the same ginkgo extract twice per day for three months was approximately as effective as 16 mg of betahistine twice daily.163

Although the precise mechanism of ginkgo biloba’s effectiveness for vertigo is unknown, there is evidence from a rodent model that ginkgo extract enhances neuronal plasticity, and aids reorganization in a variety of central nervous system structures that govern vestibular function. In that study, the administration of ginkgo extract resulted in faster recovery of balance and improved neuronal connectivity following acute inner ear damage.164

Ginger Root

Zingiber officinale (ginger) root has been used traditionally to treat digestive, inflammatory, and infectious ailments.165 A randomized controlled trial found one gram of powdered ginger strongly prevented symptoms of seasickness, including vertigo.166 Another placebo-controlled clinical trial showed ginger prevented vertigo significantly better than placebo in healthy adult subjects who underwent vestibular stimulation to induce vertigo.167 Ginger is an effective remedy for some forms of nausea168 and could be considered for treating nausea resulting from vertigo-related conditions.

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.169,170 In a case-control study, mean vitamin B12 levels were significantly lower in 114 patients newly diagnosed with BPPV compared with controls.171 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, including improvement in dizziness, in this patient.172 A study in 100 people with neurological symptoms that included dizziness and instability found that 15% of subjects had deficient or borderline low vitamin B12 levels.173

Vitamin B6

There is some historical record of vitamin B6 supplementation being used to successfully treat vertigo.174,175 Additionally, in two separate double-blind clinical trials, 20 healthy individuals were given the antibiotic minocycline (Minocin) seven times over three days in order to induce vertigo, nystagmus, and nausea. The addition of 40 mg vitamin B6 at each dose markedly reduced these side effects.176

Magnesium

Migraine has been effectively treated with oral magnesium supplementation,177-179 and magnesium supplementation may be beneficial in migraine-associated vertigo. A meta-analysis of randomized clinical trials found that, in cardiac patients, magnesium orotate supplementation reduced risk of dizziness by 78%.180 Magnesium might reduce the incidence of vestibular migraine through modulation of vascular tone and thus cerebral blood flow,181 which plays a role in the development of vestibular migraine.182

Coenzyme Q10

Coenzyme Q10 (CoQ10) is centrally involved in cellular energy production in the mitochondria and has been studied for the treatment of cardiovascular disease.183,184 In one trial, 2,664 patients with congestive heart failure were treated with 50–150 mg CoQ10 daily. After three months of treatment, 73% of participants with vertigo reported improvement in their vertigo.185 CoQ10 was shown in a mouse model to protect delicate inner ear cells from age-related decline and ward off hearing loss, leading one team of scientists to suggest it could also protect against vestibular disorders that can lead to vertigo.186,187

Glutathione and Vitamin C

Glutathione is an antioxidant that plays a critical role in several cellular processes, including scavenging reactive oxygen species and nutrient metabolism.188 Patients with BPPV, Ménière disease, and some types of centrally caused vertigo have been shown to have higher levels of oxidative stress compared with healthy individuals.66,67,189 An uncontrolled trial in 22 treatment-resistant patients with Ménière disease evaluated oral administration of 300 mg per day rebamipide (an oxidative stress medication not available in the United States) along with 600 mg per day vitamin C and/or 300 mg per day glutathione for eight weeks. Twenty-one of the 22 patients with vertigo reported complete recovery or substantial improvement. The authors concluded that oxidative stress reducers could hold potential as a treatment for Ménière disease.190

Disclaimer and Safety Information

This information (and any accompanying material) is not intended to replace the attention or advice of a physician or other qualified health care professional. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with and seek clearance from a physician or other qualified health care professional. Pregnant women in particular should seek the advice of a physician before using any protocol listed on this website. The protocols described on this website are for adults only, unless otherwise specified. Product labels may contain important safety information and the most recent product information provided by the product manufacturers should be carefully reviewed prior to use to verify the dose, administration, and contraindications. National, state, and local laws may vary regarding the use and application of many of the therapies discussed. The reader assumes the risk of any injuries. The authors and publishers, their affiliates and assigns are not liable for any injury and/or damage to persons arising from this protocol and expressly disclaim responsibility for any adverse effects resulting from the use of the information contained herein.

The protocols raise many issues that are subject to change as new data emerge. None of our suggested protocol regimens can guarantee health benefits. Life Extension has not performed independent verification of the data contained in the referenced materials, and expressly disclaims responsibility for any error in the literature.

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