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Benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo in older adults, is characterized by temporary symptoms brought on by having the head in a specific position, primarily nystagmus and vertigo. The portion of falls in an older population that can be attributed to BPPV is not clearly established, but is thought to affect approximately 10% of older individuals (often unrecognized), and be responsible for about ½ of the vertigo cases in this population. It’s important to note that some studies have found a little more than 1/3 of 75-year-olds had some type of subjective dizziness or impaired balance, and those with BPPV report more severe symptoms. A systematic review published in Age and Aging concluded that dizziness increases the risk of future falls by 63%, and nearly doubles the risk of recurrent falls.
A recent study published in Aging Clinical and Experimental Research adds to a body of evidence suggesting that vitamin D may play a role in the incidence of BPPV, potentially reducing the likelihood of falls in people with this condition. The relation between vitamin D levels and BPPV is fairly new. In 2013, a small study indicated that people with BPPV had a higher prevalence of osteopenia and osteoporosis, and BPPV was negatively correlated with 25-OH vitamin D levels, as also indicated by another study published in 2013. As will be discussed below, impaired calcium metabolism may be a contributing in each of these conditions.
The most effective treatment for BPPV remains the Canalith Repositioning Procedure (CRP), which has a success rate of approximately 80%, following only a single procedure. Yet, recurrences do happen in 10-20% of cases, and it appears that lower vitamin D levels increase the likelihood of a recurrence. For example, a retrospective review published in 2016 included over 200 patients diagnosed with BPPV; people who experienced a recurrence following a repositioning procedure had significantly lower 25-0H vitamin D levels compared to people who did not, independently of other factors, including age and gender. In another study, participants with BPPV and severe vitamin D deficiency received vitamin D supplementation, but in people who did not have a significant rise in their 25-OH vitamin D levels, their risk of recurrence was nearly 5x as much as people who did.
This most recent study set out to see if vitamin D supplementation could reduce the recurrence rate, following a single CRP, among participants with BPPV. Of the 53 participants (aged 50+), everyone received a single CRP, and those with a baseline 25-OH of ≥ 30ng/ml were (not randomly) assigned to a control group receiving only dietary advice. The remaining 39 were randomized to either a group receiving 2,000 IU vitamin D2 for 13 weeks followed by 1,000 IU for another 13 weeks, or to a group only receiving placebo for 26 weeks. All 3 groups received “dietary interventions” for the entire study period of 12 months, but what these interventions were was never specified.
The group receiving vitamin D supplementation had 0.75 significantly fewer BPPV recurrences (per one person-year) compared to the group receiving placebo, and even though the vitamin D replete (control) group also had a higher rate of recurrences than the supplemental group, this was not significant. Although more falls also occurred in the placebo group compared to the other 2 groups, this was not significant, largely due to the small size of the study (only 4 total falls occurred). Though the authors also reported a greater improvement in the 5x sit-to-stand time in people receiving vitamin D supplementation, a close look at the data indicates this was not statistically significant.
Thus, this small study suggests vitamin D supplementation among people with low 25-OH vitamin D levels may help reduce BPPV recurrence following CRP, with a suggestion that it may also reduce falls and improve physical performance, but the study may have been underpowered to confirm these last two outcomes. This supports the findings of a recent meta-analysis (published in 2022) which reviewed 5 clinical trials, only one of which was randomized, and found an overall 63% reduction in risk for BPPV recurrence with vitamin D supplementation. There was considerable heterogeneity between studies, highlighting the importance of well-controlled and powered clinical trials going forward, but this was a similar effect size to that reported in another meta-analysis of case-control studies published in 2021.
The mechanism for a benefit with vitamin D seems plausible; BPPV is thought to result from dislodged otoconia, calcium carbonate crystals (sometimes referred to as ear stones), which fall into the fluid-filled semicircular canals of the inner ear. Vitamin D receptors in the epithelial cells may regulate the expression of some of the calcium-binding proteins, with a deficiency potentially contributing to abnormal calcium metabolism in the inner ear. A number of mechanisms are in place to regulate calcium levels in the endolymph of the inner ear (calcium channel transport system, NaCa exchangers, etc.), and it may be that inadequate vitamin D levels disrupt normal otoconia development.
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