By Marcello Cherchi, MD PhD
For patients
Some researchers believe that having low levels of vitamin D may make a person have benign paroxysmal positional vertigo (BPPV), but not all researchers agree with this idea. Some researchers believe that taking extra vitamin D might protect you from having recurrences of BPPV, but not all researchers agree with this. Some research suggests that low levels of vitamin D can cause muscle loss, can cause imbalance, and can increase the risk of falls.
For clinicians
Overview
There is disagreement in the literature regarding the relationship between serum vitamin D levels and the occurrence of benign paroxysmal positional vertigo (BPPV). There is some evidence that vitamin D deficiency has adverse neuromuscular consequences (such as loss of muscle mass and strength), can adversely affect balance (in the form of increased postural sway) and can increase fall risk.
Introduction
Vitamin D plays a crucial role in the body’s metabolism of calcium and phosphorus. For purposes of otoneurology, the main question is whether vitamin D levels influence the occurrence/recurrence of benign paroxysmal positional vertigo (BPPV). Vitamin D is also relevant to maintenance of muscle mass and strength, and these neuromuscular factors may be relevant to balance and fall risk.
As far as BPPV is concerned, some literature suggests that low serum levels of vitamin D correlate with a higher incidence (first occurrence) of BPPV (Chen et al. 2021; Ding et al. 2019; Jeong and Kim 2019; Meghji et al. 2017; Rhim 2016; Sfakianaki et al. 2021; Shu et al. 2019; Talaat et al. 2015; Yang et al. 2020), and therefrom infer that low vitamin D levels are a risk factor for BPPV. Other studies find no relationship between vitamin D levels and BPPV (AlGarni et al. 2018; Goldschagg et al. 2021; Li et al. 2022), and therefrom conclude that low vitamin D levels are not a risk factor for BPPV. Other studies reach more nuanced conclusions. For example, some studies conclude that low vitamin D levels are a risk factor for recurrent BPPV (AlGarni et al. 2018; Ding et al. 2019; Talaat et al. 2015), rather than for a first episode of BPPV. Other studies note that vitamin D levels have some correlation with gender and age, and that all 3 factors must be taken into consideration when trying to assess the risk of BPPV (Song et al. 2020; Yang et al. 2017).
As far as neuromuscular factors are concerned, there is some evidence that low vitamin D levels are associated with poorer balance and with increased fall risk (Dawson-Hughes 2017).
Epidemiology
As far as benign paroxysmal positional vertigo (BPPV) is concerned, some literature has reported seasonal patterns in occurrence of BPPV (Meghji et al. 2017; Shu et al. 2019), and in particular, that BPPV is more common in winter months. The higher occurrence of BPPV in seasons with reduced light raised suspicion of a relationship with vitamin D.
Pathophysiological mechanism of disease
The mechanism by which low serum levels of vitamin D might influence the risk of BPPV is unclear (Sfakianaki et al. 2021). Otoliths are comprised of calcium carbonate, and vitamin D plays an essential role in calcium metabolism, but these facts do not in themselves prove the mechanism.
Regarding the neuromuscular role of vitamin D, it is known that vitamin D receptors are expressed in muscle tissue, and patients with vitamin D deficiency show atrophy of type 2 muscle fibers (Ceglia et al. 2013). Studies have further shown that the degree of postural sway (Cangussu et al. 2016; Pfeifer et al. 2009) and fall risk (Bischoff-Ferrari et al. 2009) are inversely correlated with vitamin D levels, though the underlying mechanisms of this inverse correlation are not clear.
Treatment
As far as benign paroxysmal positional vertigo (BPPV) is concerned, since some literature reports that lower vitamin D levels correlate with increased risk of BPPV, it is natural to wonder whether supplementing vitamin D might influence the occurrence of BPPV. There is emerging evidence that, after a first episode of BPPV, taking vitamin D and perhaps calcium may reduce the likelihood of recurrence of BPPV (Jeong et al. 2020b). For instance, a randomized controlled trial (Jeong et al. 2020a) reported that supplementation with vitamin D 400 I.U. and calcium carbonate 500 mg twice per day reduces the annual recurrence rate of BPPV. Note that increasing one’s level of vitamin D (even without supplementing additional calcium) may increase serum calcium concentrations, which at least in theory can increase the risk of developing kidney stones (Letavernier and Daudon 2018), though it is unclear whether this increased risk is clinically meaningful; one might think that vitamin D supplementation should perhaps be avoided in persons who already have a history of kidney stone formation, but this does not seem to be borne out by the evidence (Ganji et al. 2019). A person considering supplementing vitamin D intake (with or without calcium supplementation) should first consult with their primary care physician.
As far as neuromuscular factors are concerned, there is some evidence that supplementing vitamin D in patients who are deficient in vitamin D may reduce postural sway (Cangussu et al. 2016) and reduce fall risk (Bischoff-Ferrari et al. 2009).
These factors (risk of BPPV, increased postural sway, increased fall risk) add to the list of medical reasons for treating vitamin D deficiency (such as reducing the risk of bone loss and fracture risk).
References
AlGarni MA, Mirza AA, Althobaiti AA, Al-Nemari HH, Bakhsh LS (2018) Association of benign paroxysmal positional vertigo with vitamin D deficiency: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 275: 2705-2711. doi: 10.1007/s00405-018-5146-6
Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Kiel DP, Henschkowski J (2009) Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ 339: b3692. doi: 10.1136/bmj.b3692
Cangussu LM, Nahas-Neto J, Orsatti CL, Poloni PF, Schmitt EB, Almeida-Filho B, Nahas EA (2016) Effect of isolated vitamin D supplementation on the rate of falls and postural balance in postmenopausal women fallers: a randomized, double-blind, placebo-controlled trial. Menopause 23: 267-74. doi: 10.1097/GME.0000000000000525
Ceglia L, Niramitmahapanya S, da Silva Morais M, Rivas DA, Harris SS, Bischoff-Ferrari H, Fielding RA, Dawson-Hughes B (2013) A randomized study on the effect of vitamin D(3) supplementation on skeletal muscle morphology and vitamin D receptor concentration in older women. J Clin Endocrinol Metab 98: E1927-35. doi: 10.1210/jc.2013-2820
Chen J, Zhang S, Cui K, Liu C (2021) Risk factors for benign paroxysmal positional vertigo recurrence: a systematic review and meta-analysis. J Neurol 268: 4117-4127. doi: 10.1007/s00415-020-10175-0
Dawson-Hughes B (2017) Vitamin D and muscle function. J Steroid Biochem Mol Biol 173: 313-316. doi: 10.1016/j.jsbmb.2017.03.018
Ding J, Liu L, Kong WK, Chen XB, Liu X (2019) Serum levels of 25-hydroxy vitamin D correlate with idiopathic benign paroxysmal positional vertigo. Biosci Rep 39. doi: 10.1042/BSR20190142
Ganji MR, Shafii Z, Hakemi MS (2019) Vitamin D Supplementation and Risk of Hypercalciuria in Stone Formers. Iran J Kidney Dis 13: 27-31.
Goldschagg N, Teupser D, Feil K, Strupp M (2021) No evidence for a specific vitamin D deficit in benign paroxysmal positional vertigo. European Journal of Neurology. doi: 10.1111/ene.14980
Jeong SH, Kim JS (2019) Impaired Calcium Metabolism in Benign Paroxysmal Positional Vertigo: A Topical Review. J Neurol Phys Ther 43 Suppl 2: S37-S41. doi: 10.1097/NPT.0000000000000273
Jeong SH, Kim JS, Kim HJ, Choi JY, Koo JW, Choi KD, Park JY, Lee SH, Choi SY, Oh SY, Yang TH, Park JH, Jung I, Ahn S, Kim S (2020a) Prevention of benign paroxysmal positional vertigo with vitamin D supplementation: A randomized trial. Neurology 95: e1117-e1125. doi: 10.1212/WNL.0000000000010343
Jeong SH, Lee SU, Kim JS (2020b) Prevention of recurrent benign paroxysmal positional vertigo with vitamin D supplementation: a meta-analysis. J Neurol. doi: 10.1007/s00415-020-09952-8
Letavernier E, Daudon M (2018) Vitamin D, Hypercalciuria and Kidney Stones. Nutrients 10. doi: 10.3390/nu10030366
Li S, Wang Z, Liu Y, Cao J, Zheng H, Jing Y, Han L, Ma X, Xia R, Yu L (2022) Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis. Ear Nose Throat J 101: NP112-NP134. doi: 10.1177/0145561320943362
Meghji S, Murphy D, Nunney I, Phillips JS (2017) The Seasonal Variation of Benign Paroxysmal Positional Vertigo. Otol Neurotol 38: 1315-1318. doi: 10.1097/MAO.0000000000001534
Pfeifer M, Begerow B, Minne HW, Suppan K, Fahrleitner-Pammer A, Dobnig H (2009) Effects of a long-term vitamin D and calcium supplementation on falls and parameters of muscle function in community-dwelling older individuals. Osteoporos Int 20: 315-22. doi: 10.1007/s00198-008-0662-7
Rhim GI (2016) Serum vitamin D and recurrent benign paroxysmal positional vertigo. Laryngoscope Investig Otolaryngol 1: 150-153. doi: 10.1002/lio2.35
Sfakianaki I, Binos P, Karkos P, Dimas GG, Psillas G (2021) Risk Factors for Recurrence of Benign Paroxysmal Positional Vertigo. A Clinical Review. J Clin Med 10. doi: 10.3390/jcm10194372
Shu L, Wu J, Jiang CY, Sun XH, Pan H, Fang J, Tang Y, Wu SC, Liu JR, Chen W (2019) Seasonal variation of idiopathic benign paroxysmal positional vertigo correlates with serum 25-hydroxyvitamin D levels: a six-year registry study in Shanghai, China. Sci Rep 9: 16230. doi: 10.1038/s41598-019-52803-4
Song P, Zhao X, Xu Y, Zhao Z, Wang L, Liu Y, Gao Q (2020) Correlation Between Benign Paroxysmal Positional Vertigo and 25-hydroxyvitamin D. Front Neurol 11: 576. doi: 10.3389/fneur.2020.00576
Talaat HS, Abuhadied G, Talaat AS, Abdelaal MSS (2015) Low bone mineral density and vitamin D deficiency in patients with benign positional paroxysmal vertigo. European Archives of Oto-Rhino-Laryngology 272: 2249-2253. doi: 10.1007/s00405-014-3175-3
Yang B, Lu Y, Xing D, Zhong W, Tang Q, Liu J, Yang X (2020) Association between serum vitamin D levels and benign paroxysmal positional vertigo: a systematic review and meta-analysis of observational studies. Eur Arch Otorhinolaryngol 277: 169-177. doi: 10.1007/s00405-019-05694-0
Yang CJ, Kim Y, Lee HS, Park HJ (2017) Bone mineral density and serum 25-hydroxyvitamin D in patients with idiopathic benign paroxysmal positional vertigo. Journal of Vestibular Research 27: 287-294.
