Twice daily vitamin D supplementation reduces symptoms of vertigo for those suffering BPPV

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Taking vitamin D and calcium twice a day may reduce your chances of getting vertigo again, according to a study published in the August 5, 2020, online issue of Neurology.

“Our study suggests that for people with benign paroxysmal positional vertigo, taking a supplement of vitamin D and calcium is a simple, low-risk way to prevent vertigo from recurring,” said Ji-Soo Kim, M.D., Ph.D., of Seoul National University College of Medicine in Korea.

“It is especially effective if you have low vitamin D levels to begin with.”

Benign paroxysmal positional vertigo happens when a change in head position gives you a sudden spinning sensation.

It’s one of the most common types of vertigo.

Treatment includes a doctor performing a series of head movements that shift particles in the ears that cause the vertigo, but the condition tends to recur frequently.

About 86% of people with this form of vertigo find that it interrupts their daily life or causes them to miss days at work.

The study looked at 957 people in Korea with benign paroxysmal positional vertigo who were treated successfully with the head movements.

The participants were separated into two groups, intervention and observation.

The 445 people in the intervention group had their vitamin D levels taken at the start of the study. The 348 people with vitamin D levels below 20 nanograms per milliliter (ng/mL) were started on supplements with 400 international units of vitamin D and 500 milligrams of calcium twice daily, while those with vitamin D levels equal to or greater than 20 ng/mL were not given supplements.

The 512 people in the observation group did not have their vitamin D levels monitored and they did not get supplements.

Those in the intervention group who took the supplements had a lower recurrence rate for vertigo episodes after an average of one year than those in the observation group.

People taking supplements had an average recurrence rate of 0.83 times per person-year, compared to 1.10 times per person-year for those in the observation group, or a 24% reduction in the annual recurrence rate.

There appeared to be greater benefit for those who were more deficient in vitamin D at the start of the study.

Those who started with vitamin D levels lower than 10 ng/mL saw a 45% reduction in annual recurrence rate, while those starting with vitamin D levels at 10 to 20 ng/mL saw only a 14% reduction.

A total of 38% of the people in the interventional group had another episode of vertigo, compared to 47% of those in the observation group.

“Our results are exciting because so far, going to the doctor to have them perform head movements has been the main way we treat benign paroxysmal positional vertigo,” said Kim.

“Our study suggests an inexpensive, low-risk treatment like vitamin D and calcium tablets may be effective at preventing this common, and commonly recurring, disorder.”

A limitation of the study is that a large number of participants did not complete the entire study, with more people assigned to take the supplements dropping out of the study than in the observation group.


Benign paroxysmal positional vertigo (BPPV) is the most common neuro-otological disorder [1]. Today it is accepted, that it is caused by dislodged otoconia, which fall from the utricular macula and float into the semicricular canals thereby making them sensitive to gravity [2].

Otoconia crystals have distinct central cores and peripheral zones (for review see [3]). The core is predominantly organic with a lower level of Ca2+, and the periphery is largely inorganic with a higher level of Ca2+ [4].

The core, periphery and external surface of the crystals all have inter-connecting fibrous material with varied diameters and organization. The main inorganic mineral component is almost exclusively a polymorph of calcium carbonate (CaCO3).

The organic component is usually a predominant glycoprotein. Otoconia crystals are partially embedded in a membranous/fibrous matrix and are tethered by proteinaceous filaments to the kinocilium of the underlying hair cells.

The formation of otoconia surrounded by low-calcium endolymph is a tigthly controlled active process [3].

It has been shown that elderly people may suffer from unrecognized, chronic BPPV. In 2000 a widely cited cross-sectional study was published, which determined the prevalence of unrecognized benign paroxysmal positional vertigo (BPPV) in an inner-city geriatric population [5].

Dizziness was found in 61% of patients. Nine percent were found to have unrecognized BPPV. Patients with unrecognized BPPV were more likely to have reduced activities of daily living scores, to have sustained a fall in the previous 3 months, and to have depression.

These data indicated that unrecognized BPPV is common within the elderly population and has associated morbidity.

Apart from classical BPPV with nystagmus chronic subjective BPPV without nystagmus may also be common, recently a mechanism for that has been suggested [6].

Osteoporosis and BPPV

Back in 2003 Vibert et al suggested a connection between BPPV, osteoporosis and osteopenia [7].

Since then another independent group also showed that bone metabolism has a connection to BPPV [8]. Recent studies in Dr. Lundberg’s laboratory show common features between bone and otoconia biomineralization.

For example, the organization of the matrix is similar between the two tissues, and most of the protein constituents are present in both tissues.

Similar to that in bone and teeth, biomineralization in otoconia involves tight regulation of the formation of an organic matrix at specific sites and the deposition of mineral crystallites in an ordered manner [9–11, Lundberg, unpublished data].

In animal experiments it has been shown that this process is dysfunctional in osteoporosis [12]. Even a beneficial therapeutic effect could be observed between BPPV and osteoporosis when treated with bisphosphonates in women [13].

Osteoporosis and Vitamin D

The effect of vitamin D on osteoporosis has been established in the literature (for review see [14]). Calcium and vitamin D play important roles in improving bone mineral density and reducing the risk of fracture [15].

It is also known that vitamin D supplementation reduces the risks of falls and fractures in elderly people [16]. According to these authors this may be due to the effect of vitamin D by improving neuromuscular function.

Consequences of the hypothesis and discussion

We found that our patients with idiopathic BPPV had low average vitamin D serum levels (23 ng/mL). This is similar to that of the general Austrian population (in average 20.9 mg/mL [20]), which has a high prevalence of vitamin D hypovitaminosis.

We identified 4 patients, who had been having recurrent episodes of BPPV for a longer time before the examination with a frequency of 4–6 relapses/year for several years.

These patients as a subgroup had significantly lower average serum level of 25(OH)D than patients in the subgroup in which with a first episode.

After having been supplemented with vitamin D, BPPV patients have not encountered relapses in the follow up period of at least 8 month.

Although some BPPV cases are benign, most cases recur. In a recent study the recurrence rate of BPPV was 27%, and relapse largely occurred in the first 6 months ([21]).

At present, the generally accepted recurrence rate of BPPV after successful treatment is 40 to 50% at 5 years of average follow up.

A subset of individuals appears prone to multiple recurrences [21, 22]. In our study in 4 cases with chronically recurrent severe BPPV episodes low levels of serum 25(OH)D could be measured, and, BPPV did not recur after supplementation with Vitamin D.

These preliminary results show that a hypothesis linking vitamin D and BPPV may be valid. Although we cannot rule out coincidence at the present, given the multiple benefits of vitamin D, we recommend supplementation in BPPV cases.

The so-called classical effects of vitamin D are that on bone density, bone quality and muscle performance. In this context, it is listed among the classical effects that falling of elderly people was significantly reduced in vitamin D supplemented individuals compared to those receiving calcium and placebo [23, 24].

Theoretically it may even be possible that supplementation with vitamin D brings about a decrease of falls through decreasing the frequency of unrecognized BPPV. Even if this not the case, it is easy to see that perhaps a synergistic relationship may be influenced by correcting abnormally low vitamin D levels.

In the literature the possibility of numerous other, so-called non-classical effects also have been described (cardiovascular, diabetes mellitus, cancer, multiple sclerosis, allergy, asthma (see Review[19]).

These authors also classified vitamin D status according to measured 25(OH)D concentration: less than 10 ng/mL: deficient; between 11–20: insufficient; higher than 20 ng/ml: optimal.

Recently an international panel reached agreement about the need for vitamin D supplementation in specific groups of patients in these clinical areas and the need for assessing their 25-hydroxyvitamin D (25(OH)D) serum levels for optimal clinical care.

A target range of at least 30 to 40 ng/mL was recommended ([17]). The mechanism of the beneficial effect of vitamin D may involve improvement of pathologic biomineralization of otoconia similar to that of bone and teeth.

We decided to publish our hypothesis because of the following reasons:

  • According to theoretical considerations the existence of a link between otolithic disturbances and vitamin D deficiency is highly probable
  • Given the prevalence of vitamin D deficiency and the simplicity of the procedure (measurement of vitamin D levels and supplementation if necessary) the recommended correction should be done anyway
  • BPPV is so common, that even if the supplementation of vitamin D inhibits recurrence only in a small percentage of cases, this means a large number of cases with improvement

We suggest further statistical epidemiological investigations to determine average serum levels of 25(OH)D in patients with BPPV and the effect of correcting vitamin D deficiency on the recurrence of BPPV.

Even until these results are available, given the other known benefits of vitamin D, we recommend measurement of 25(OH)D and supplementation if necessary.

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Figure 1
Our hypothesis establishes connection between vitamin D and BPPV. The arrows show the connections established in the literature so far, the question mark designates the hypothetical connection

References

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