Vertigo is a sensation of motion or spinning that is often described as dizziness.

Vertigo is not the same as light-headedness. People with vertigo feel as though they are actually spinning or moving, or that the world is spinning around them.

Causes

There are two types of vertigo:

• Peripheral vertigo occurs if there is a problem with the part of the inner ear that controls balance (vestibular labyrinth or semicircular canals) or with the vestibular nerve, which connects the inner ear to the brainstem.
• Central vertigo occurs if there is a problem in the brain, particularly in the brainstem or the back part of the brain (cerebellum).

Vertigo related to the inner ear may be caused by:

• Benign positional vertigo (also called benign paroxysmal positional vertigo)
• Drugs called aminoglycoside antibiotics
• Injury (such as head injury) (see Concussion / Brain Injury / Traumatic Brain Injury)
• Labyrinthitis
• Ménière’s disease (seeTinnitus / Meniere’s Syndrome)

Vertigo related to the vestibular nerve may be caused by:

• Inflammation (neuronitis) (see Peripheral Nerve Disorders)
• Nerve compression (usually a noncancerous tumor such as a meningioma or schwannoma)

Vertigo related to the brainstem may be caused by:

• Blood vessel disease (see Peripheral Artery (Arterial) Disease (PAD) and Claudication / Atherosclerosis)
• Drugs / Medications (anticonvulsants, antidepressants, aspirin, alcohol, etc. – see below)
• Migraine (see Headaches (Nonvascular and Vascular / Migraine))
• Multiple sclerosis (see Multiple Sclerosis (MS))
• Seizures (rarely) (see Tics / Tremors / Seizures / Epilepsy / Tourette Syndrome)

Medications

Feeling dizzy or lightheaded (vertigo) is one of the most common side effects of many prescription drugs. Medications that cause a sudden drop in blood pressure, dehydration, or low blood sugar can trigger dizziness.

• Anticonvulsants

Used for: Bipolar disorder, diabetic neuropathy, epilepsy, and fibromyalgia.

Examples: Divalproex (Depakote), gabapentin (Neurontin), and pregabalin (Lyrica).

What to try instead: If you have epilepsy, keep taking your meds and ask your doctor about whether you need a drug-level check, adjustment of your dosing schedule, or a different medication. Talk to your doctor about other options that might be safer and work better.  (see Tics / Tremors / Seizures / Epilepsy / Tourette Syndrome)

• Antidepressants

Used for: Depression and anxiety.

Examples: Fluoxetine (Prozac), sertraline (Zoloft), and trazodone (Desyrel).

What to try instead: Counseling or psychotherapy can often help as much or more than medication, especially for mild depression. But don’t suddenly stop taking an antidepressant—or any prescription drug—without your doctor’s OK. Doing so could trigger withdrawl symptoms. (see Depression / Negative Mood OR Anxiety Disorders)

• Blood Pressure Drugs

Used for: High blood pressure.

Examples: All drugs used to treat the condition, including ACE inhibitors such as lisinopril (Zestril), beta-blockers such as propranolol (Inderal), metoprolol (Lopressor), diuretics such as furosemide (Lasix) and hydrochlorothiazide, and calcium-channel blockers such as amlodipine (Norvasc) .

What to try instead: Losing weight—with exercise and a healthy diet—can reduce or even eliminate the need for drugs. If that doesn’t lower your blood pressure enough, ask your doc about trying a different drug or combination of drugs. (see Hypertension (High Blood Pressure))

• Muscle Relaxants

Used for: Back, head, and neck pain.

Examples: Cyclobenzaprine (Amrix) and metaxalone (Skelaxin).

What to try instead: There is scant evidence showing that those drugs work, so first try nondrug therapies such as a heating pad, exercise, biofeedback, physical therapy, progressive relaxation, massage, and yoga. You might also want to try an over-the-counter pain reliever, such as ibuprofen (Advil and generic) or naproxen (Aleve and generic). They also have been associated with dizziness, but it’s rare. (see Restless Legs Syndrome and Leg Cramps)

• Nitroglycerin

Used for: Angina (chest pain).

What to try instead: There is no substitute for nitroglycerin, but you can reduce your risk of dizziness by sitting down before taking it and remaining seated for up to 5 minutes afterward, says our Chief Medical Consultant, Marvin M. Lipman, M.D.

• Pain Relievers

Used for: Pain.

Examples: Hydrocodone (an opioid) and over-the-counter ibuprofen and naproxen.

What to try instead: For everyday pain, try acetaminophen (Tylenol and generic). (see Pain / Inflammation Management)

• Sleeping Pills

Used for: Insomnia.

Examples: Diphenhydramine (Benadryl, Unisom, Sominex), temazepam (Restoril), eszopiclone (Lunesta), and zolpidem (Ambien).

What to try instead: New treatment guidelines for insomnia suggest that type of talk therapy called cognitive behavioral therapy may work as well as or even better than sleeping pills. Also try improving your sleep by avoiding caffeine and alcohol after dinner and turning off computers and TV within 1 hour of bedtime. (see Sleep Disorders / Insomnia)

References: 

• Vertigo-associated disorders: MedlinePlus Medical Encyclopedia 
• <https://www.consumerreports.org/drug-safety/drugs-that-might-be-the-cause-of-your-dizziness/>

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Natural Approaches to Vertigo-associated Disorders

Try to identify triggering agent(s):

• Inner ear dysfunction (see Tinnitus / Meniere’s Syndrome)
• Ear Infection (see Ear Infection (Otitis Media))
• Migraines (see Headaches (see Headaches (Nonvascular and Vascular / Migraine))
• Anemia (see Iron-Deficiency / Iron-Deficiency Anemia)
• Cerebellar Stroke (see Stroke | Post-Stroke Nutritional Support Considerations)
• Nerve inflammation or compression as a result of head injury (seePeripheral Nerve Disorders OR Concussion / Brain Injury / Traumatic Brain Injury)
• Medication use (see list above)

NOTE: Taking vitamin D and calcium twice a day may reduce chances of getting vertigo again, according to a study published in the August 5, 2020, online issue of Neurology®, the medical journal of the American Academy of Neurology.

Consider:

• Bone Support 

Bone Support is a natural dietary supplement formulated with microcrystalline hydroxyapatite concentrate (as patented MCH-Cal™), providing bioavailable calcium and phosphorus for supporting bone function, bone integrity, teeth, and other physiological processes. This supplement also features an evidence-based dose of vitamin D3 (as cholecalciferol) to support bone mineral density and calcium absorption.

Reference: Seong-Hae Jeong, Ji-Soo Kim, Hyo-Jung Kim, Jeong-Yoon Choi, Ja-Won Koo, Kwang-Dong Choi, Ji-Yun Park, Seung-Han Lee, Seo-Young Choi, Sun-Young Oh, Tae-Ho Yang, Jae Han Park, Ileok Jung, Soyeon Ahn, Sooyeon Kim. Prevention of Benign Paroxysmal Positional Vertigo with Vit D Supplementation: A Randomized Trial. Neurology, 2020; 10.1212/WNL.0000000000010343 DOI: 10.1212/WNL.0000000000010343

If the Vertigo is Benign Paroxysmal Positional Vertigo (BPPV), consider the “Epley particle repositioning maneuver” (see  below)

Out of 40 patients, 20 underwent PRM (Epley particle repositioning maneuver) with the rest receiving a placebo treatment. Postprocedural instructions were given to all the patients who underwent PRM. Follow-up was for 1 year at regular intervals. Analysis was based on the symptomatic status and the Hallpike maneuver at each visit.

Results

After the initial week, 95% showed complete resolution of symptoms with none reporting a recurrence after PRM. On the contrary, only 15% of the controls had complete resolution with 14 out of 20 reporting a recurrence of BPPV. Results remained more or less the same at the end of 4 weeks. Six months after PRM, 19 of 20 patients had no vertigo with a meager 5% showing recurrence versus 75% of controls reporting a recurrence with only 3 of 20 reporting a favorable symptom status. At the end of 1 year, 18 of 20 patients had complete relief from symptoms with only 10% showing Hallpike maneuver positive in the study group compared with 3 of 20 reporting a relief from symptoms with 90% turning out to be Hallpike maneuver positive in the control group.

Conclusions

This study establishes the efficacy of PRM in short- and long-term management of BPPV; the procedure is easy and simple.

Reference: Efficacy of particle repositioning maneuver in BPPV: a prospective study – American Journal of OTOLARYNGOLOGY – November–December, 2003Volume 24, Issue 6, Pages 355–360 – DOI: https://doi.org/10.1016/S0196-0709(03)00069

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Epley Particle Repositioning Maneuver: A Treatment for Vertigo

By Lana Burgess – Last reviewed – Wed 30 August 2017 – Reviewed by Alana Biggers, MD, MPH

The Epley particle repositioning maneuver is an exercise performed to treat a type of vertigo called benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is caused by a problem in the inner ear. It is often associated with aging, but head injuries can also cause it. The Epley maneuver can be carried out by a doctor or at home by the individual experiencing BPPV to relieve symptoms. This article provides a step-by-step guide to the Epley maneuver and examines how the treatment works.

What is the Epley maneuver?

The purpose of the Epley maneuver is to dislodge crystals in the ear that may be affecting balance.

The Epley maneuver is a series of movements, normally carried out on a person by a doctor, to relieve the symptoms of BPPV. Research has found it to be an easy, safe, and effective treatment for the condition in both the long- and short-term.

The Epley maneuver is sometimes called the particle repositioning maneuver or the canalith repositioning maneuver.

These names are used because the maneuver involves a series of movements that help to reposition crystals in a person’s ear that may cause feelings of dizziness. Repositioning the crystals helps to relieve the person’s dizziness and nausea.

A doctor doing the Epley maneuver will manually move a person into a series of positions. It can also be done at home by the person experiencing the BPPV symptoms. The steps for both versions are detailed below.

Steps of the Epley Maneuver Carried Out by a Doctor:

When a doctor carries out the Epley maneuver, they will perform the following steps:

• Ask the person to sit upright on an examination table, fully extending their legs out in front of them.
• Rotate the person’s head at a 45-degree angle towards the side they are experiencing the worst vertigo.
• Quickly push the person back, so that they are lying down with their shoulders touching the table. The person’s head is kept facing the side worst affected by vertigo but now at a 30-degree angle, so that it is lifted slightly off the table. The doctor holds the person in this position for between 30 seconds and 2 minutes, until their dizziness stops.
• Rotate the person’s head 90 degrees in the opposite direction, stopping when the opposite ear is 30 degrees away from the table. Again, the doctor holds the person in this position for between 30 seconds and 2 minutes, until their dizziness stops.
• Next, they roll the person in the same direction that they are facing, onto their side. The side that they experience the worst vertigo on will be facing upwards. The doctor holds the person in this position for between 30 seconds and 2 minutes, until their dizziness stops.
• Finally, the doctor brings the person back up to a sitting position.
• The whole process is repeated up to three times, until the person’s symptoms are relieved.

Steps of the Epley Maneuver Carried Out at Home:

It is best for a doctor to carry out the Epley maneuver if the person experiencing BPPV has not used this method before.

Once a person has had the Epley maneuver performed by a doctor, they may want to repeat the process at home if they have further symptoms.

A person experiencing BPPV symptoms can follow these steps to gain relief at home:

• Sit up in bed with the legs extended in front of them and turn their head 45 degrees to the side that they are experiencing the most dizziness.
• Lie down, keeping their head turned to the side and lifted at a 30-degree angle away from the bed. They should stay in this position for 30 seconds to 2 minutes, until their dizziness stops.
• They should then turn their head 90 degrees in the other direction and stop when it is 30 degrees from the bed on the other side. Again, the person should hold this position for 30 seconds to 2 minutes, until their dizziness stops.
• They should now roll onto their side in the direction their head is facing, holding this position until the dizziness stops.

When to Use

A doctor will use the Epley maneuver to help relieve a person’s dizziness and nausea when they have decided that BPPV is the cause.

The Epley maneuver is not suitable to treat vertigo caused by something other than BPPV. If a person is unsure what is causing their vertigo, they should speak to a doctor and ask to be examined.

Other causes of vertigo include:

• migraines
• ear infections
• anemia
• cerebellar stroke

Having been shown the Epley maneuver by a doctor, someone with BPPV can repeat it themselves at home whenever they need to relieve their symptoms.

People often find it is useful to do the Epley maneuver before going to bed, as tossing and turning can trigger symptoms.

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