Table 1.
Benefit | Intervention | Mechanism(s) | Action(s) |
---|---|---|---|
Reduce/delay otoconial detachment | Vitamin D supplementation† | Maintain low endolymph Ca2+ to prevent abnormal otoconia (55). |
|
Betahistine† | Regulation of intracellular calcium (51). |
|
|
Maintain capacity to dissolve exfoliated otoconia | Vitamin D supplementation† | Maintain low endolymph Ca2+ to retain capacity to dissolve exfoliated otoconia (55). |
|
Improve static components | Betahistine† | Rebalancing of the vestibular nuclei neurons (51–53). | |
Improve labyrinthine microcirculation | Betahistine† | Increases local vestibular blood flow (56). | |
Management of vascular comorbidities‡ | Vascular comorbidities such as hypertension, dyslipidemia, obesity, and diabetes, may be risk factors for BPPV recurrence (59). |
|
|
Aid central vestibular compensation | Gaze stabilization techniques‡ | Reduce symptoms of dizziness and vertigo (61). |
|
Balance training‡ | Improved symptom resolution in posterior canalithiasis BPPV (62). |
|
|
Betahistine†‡ | Brain arousal, a crucial factor for functional recovery/behavioral adaptation, through general upregulation of histamine (15, 50, 58).† | ||
Increase histamine turnover and release, and modulation of release of other neurotransmitters, particularly GABA that facilitate late-stage vestibular compensation (50, 64, 65).† | |||
Promote vestibular compensation of both static and dynamic symptoms: mediation of the asymmetric activation of commissural inhibitory system at circuit level; actively promotes rebalancing of bilateral vestibular systems and vestibular compensation (58).† |
|
||
Enhance the rebalancing of the neuronal activity of the vestibular nuclei complexes on both sides (50, 64)† and (67).‡ |
*Current guidelines recommend against the routine treatment of patients with BPPV with vestibular suppressant medications such as antihistamines [dimenhydrinate, cinnarizine, meclizine, promethazine (54), and/or benzodiazepines (27)]. Vestibular suppressant medications (especially benzodiazepines) have the potential for significant harm and may produce drowsiness, cognitive deficits, and interference with driving or operating machinery. Benzodiazepines and antihistamines interfere with central compensation for a vestibular injury (27). †Evidence from animal studies. ‡Evidence from clinical studies. BPPV, Benign paroxysmal positional vertigo; Ca, Calcium; CNS, Central nervous system; CRM, Canalith repositioning maneuver; GABA, Gamma-aminobutyric acid; and TC, Total cholesterol.