Marys Medicine

Thebsa.org.uk

I am sorry to hear you have been troubled by symptoms of imbalance and dizziness. Your query appears to contain two elements: 1) dizziness and imbalance related to the time of year, and 2) complementary therapies or supplements for dizziness and imbalance. I will cover these in two sections below. I admit I do not routinely provide much advice in these areas, and don't think other clinicians allied to a more 'medical' model commonly would either. I think this is because there is not enough evidence to back up any recommendations, although I would hope anyone would be open minded to the possibility of stronger evidence becoming available. I have looked at the scientific literature for you, in case I have been missing something. Both of these areas appear to be poorly understood and controversial. The scientific research proves confusing and contradictory, but I will attempt to summarise what I have discovered. Some of the difficulty in carrying out research in these areas relates to different definitions of dizziness, imbalance and vertigo. Often people use the term dizziness to cover feeling light-headed, woozy, giddy, floaty, or unsteady. Vertigo is a term more often used by clinicians and scientists with a stricter definition of an illusion of movement of one's self or the environment, often spinning or rotational sensations. Individuals often mean very different things when they say they are dizzy, and research studies have often defined and categorised dizziness differently when you compare them. Patients get allocated into treatment groups in the studies in quite varying ways. Dizziness and vertigo can be related to many different underlying conditions and it is likely that these conditions need to be considered separately in research studies, but this is often not the case. Finding effective treatments for specific conditions can be compromised when patients are grouped in research studies into a general ‘dizzy patient' category. Vertigo is often the subject of research studies rather than dizziness as vertigo is often considered a defining feature of vestibular disorders (conditions related specifically to the vestibular or balance system, including the vestibular or balance organs in the inner ear), which it is sometimes possible to more clearly define. Any understanding of vertigo might not relate to symptoms of dizziness or imbalance though. I have put my overall summary of these areas first so that you might obtain some quick guidance. More specific and detailed information is then provided if you wish to read further, but these sections are denser to read. In summary There are relatively small numbers of studies into both the seasonality of dizziness and balance disorders, and complementary medicine and therapy in dizziness and imbalance. The studies tend to present conflicting results. Those that have been carried out often use unsatisfactory research methods, use small numbers of subjects, and are liable to publications bias (for example, studies published by the manufacturers of supplements). There is a distinct lack of the ‘gold standard' randomised, double-blind, controlled studies. If you are experiencing seasonal symptoms it is difficult to advise how to manage this as it is difficult to assert any control over the seasons, the weather, or barometric changes. If you are able to determine any triggers that are controllable or avoidable then that would be recommended. Hain (2015) advises to treat any allergy or migraine triggers appropriately, and to try any appropriate treatment prior to the anticipated onset of symptoms. If someone has migraine then we would expect there might be triggers that cause symptoms. Being able to identify triggers might help someone determine that they suffer from migraine. It is important to note that an individual can have migraine or vestibular migraine without any headache, which can mean this diagnosis can be missed. VEDA (2015) advice to patients is to avoid anxiety, as we know this can potentially make any symptoms of dizziness worse, and to educate themselves. I have attached a leaflet from the Meniere's Society that outlines some possible causes of dizziness and imbalance which might help you to decide whether any of the conditions fit with your symptoms. I have also attached a leaflet on vestibular migraine in view of Timothy Hain's perceived link between season and migraine, although I appreciate you do not think you have migraine, just in case any of it seems relevant to you. I would recommended the Meniere's Society and VEDA for information and support if you have not already come across them. Their websites can be found atand espectively. Always seek the advice of your GP before undertaking complementary therapies or taking complementary supplements. Always check the certification of any complementary therapist you are considering using (Asher and colleagues, 2001). Overall, further research is required into any seasonal variation in vertigo, dizziness and imbalance which might be related to specific conditions. If particular links could be established then research could be carried out to determine the underlying pathophysiology (what is going wrong with the normal function of the body) of seasonal variation, which in turn could aid the development of any appropriate treatments. The scientific literature does not appear to currently support the routine recommendation of complementary supplements for vertigo or dizziness due to lack of compelling evidence for their effectiveness. Complementary supplements might be suitable to incorporate into a management plan if a patient so desires but they should be aware of the pros and cons of taking them. It is important to consider that complementary supplements can interact with other medicines and you may need to be cautious if you have particular medical conditions. Any recommendations for complementary therapies would need to be considered on a case by case basis. If you would like more information, investigation or advice then you might want to explore with your GP the possibility and your suitability for a referral to an Ear, Nose and Throat consultant or Audiovestibular Physician with a special interest in balance disorders. A thorough examination by them, possibly when you are more likely to be symptomatic, might determine whether there is any underlying condition responsible for your symptoms or, indeed, rule out any ear problem. 1. Dizziness and imbalance related to the time of year In my experience, that of colleagues who have worked extensively with patients with problems with dizziness and imbalance, and looking at the scientific literature, there are a small but not insignificant number of individuals who relate their symptoms to time of year, season or the weather. The Meniere's Society in the United Kingdom, which supports individuals with dizziness and imbalance due to any condition, tell me that they often have queries regarding dizziness and the weather. I have attached a summary of a recent discussion on the Meniere's Society Facebook page on this subject. I hope this reassures you that you are not alone in reporting symptoms related to the time of year, or situations that might be linked to the time of year such as weather changes. Timothy Hain in Chicago, a leading clinician and authority on balance disorders, relates experiences of patients who report vertigo occurring in the same month, every year (Hain, 2015). He thinks this could be migraine, allergy or Seasonal Affective Disorder related. The Vestibular Disorders Association (VEDA) has an article on their website on patients reporting vertigo related to weather and barometric changes (VEDA, 2015). Again, quoting Timothy Hain, they relate this to migraine. They outline that patients often report their symptoms are related to rapid changes in weather, such as that occurring before a storm, and often in spring and autumn when weather patterns change (VEDA, 2015). These reports remain largely anecdotal, however. The scientific community has tried to understand these phenomena and to determine any true relationships in a small number of research studies. Any true relationships need to be distinguished from patterns that might be seen in symptoms in an attempt to make sense of them, but possibly are a coincidence. The research remains scarce and contradictory. In the research any seasonal distribution of symptoms or conditions has been thought most likely related to climatic variables. Pereira (2015) cites some studies suggesting some seasonal variation in vertigo (Lai and colleagues, 2011); and the specific vertigo related disorders Meniere's disease (Celestino and colleagues, 1987), and Benign Paroxysmal Positional Vertigo (Mariani and colleagues, 2008). Mariani and colleagues (2008) claim there are studies showing that atmospheric pressure can affect well-being and medical conditions, and that some individuals are more sensitive to weather than others. They studied Benign Paroxysmal Positional Vertigo (BPPV) themselves and found it related to the winter season, with an increased number of attacks of BPPV related to lower temperature (and by inference decreased sun radiation). They had no suggestions for the links between the two factors. (Please see the information below in the complementary therapies section on Vitamin D3 for BPPV, as the research mentioned there might support a link between increased incidence of BPPV and decreased sun radiation, related to potential for lower Vitamin D levels in individuals in winter. I'm not sure the potential link between these studies has been made before so I will be researching the academic literature further)! Another study, in Brazil, found no seasonal variation in vestibular disorders more generally (Bilecki and colleagues, 2005). Several studies have researched any relationship between seasonal change and the likelihood of viral illness (Koors and colleagues, 2013). Koors and colleagues in 2013 were the first to study this in the inner ear disorder vestibular neuritis (or neuronitis), which leads to vertigo, dizziness and imbalance, and is often assumed to have a viral cause (although this may not be the case). They found minimal evidence for seasonality of vestibular neuritis, which they noted as consistent with other studies of inner ear disorders thought to be viral. Other studies of season and inner ear disorder, such as unexplained sudden hearing loss, have been inconclusive with the better studies showing no relationship (Koors and colleagues, 2013). But a small amount of their data from a single year (but not the years grouped together) did support a monthly or seasonal variation. They suggested larger scale studies were required. More recently, Adamec and colleagues (2015) mention previous claims that vestibular neuritis may be more common in spring and early summer (Baloh, 2003), but their study showed no evidence for seasonality for vestibular neuronitis either. Pereira and colleagues (2015) found a difference in seasonality between dizziness and vertigo. Their study, carried out in a tropical region, showed a peak in dizziness in later summer (associated with higher temperature, higher rainfall, lower barometric pressure), and lower incidence in winter. On the other hand vertigo was found to peak in later winter (associated with lower rainfall and lower humidity), and had a lower incidence in late summer. They note that their findings of a winter-spring peak for vertigo agrees with the Mariani (2008) study carried out in Italy, and the Lai (2011) study carried out in Taiwan, but disagrees with a summer peak for vestibular neuritis found by Siddiqui (2011) in their study carried out in Pakistan. As you see the research on this topic has resulted in mixed findings. If any true relationships between dizziness, vertigo or imbalance and seasonality exist, the reasons are unknown. Some ideas that have been suggested are: 1. Return of dizziness symptoms due to being unwell with upper respiratory tract infections / colds in the winter, when a previous balance event or condition had been adjusted to up until that point (in technical terms, decompensation to a previously compensated condition) 2. Dizziness related to allergens and allergies in the summer 3. Dizziness related to levels of light in winter, affecting melatonin for example, possibly influencing mood and sleep, and potentially leading to Seasonal Affective Disorder 4. Seasonal variation of blood pressure and glucose with possible related periods of hypotension (low blood pressure) or hypoglycemia (low glucose), that might either cause dizziness 5. Climate factors somehow affecting the fluid equilibrium in the inner ear But this all remains speculation only. 6. Complementary medicine or therapy as treatment for dizziness and imbalance The medical and scientific community is interested in determining whether any complementary medicine or therapy can provide effective management for balance disorders and their related symptoms. If a complementary therapy or supplement is proven to work then clinicians are likely to be very pleased and it will quickly be incorporated into routine medical practice! The American Association of Otolarngology (Ear, Nose and Throat) – Head and Neck Surgery has set up a Committee on Complementary & Integrative Medicine (CIM) to provide information on any potential beneficial or harmful CIM practices to their members. Unfortunately they have not yet published any recommendations relating to CIM and dizziness, vertigo or imbalance but I would hope they will try to cover this topic amongst the many others relevant to them when time and resources allow. I found two articles reviewing the scientific literature on complementary medicine and therapies in the Ear, Nose and Throat speciality - those by Asher and colleagues (2001), and Karkos and colleagues (2007). This means summaries of this area for the clinician or patient are very limited and now a little dated. Some of the most common complementary therapies that have been suggested for vertigo, dizziness and imbalance, and related symptoms such as nausea and vomiting, are T'ai Chi, herbs to include ginkgo biloba extract, ginger, and homepathic remedies such as Vertigoheel. A summary of the potential pros and cons of each of these is given below. It is important to note that because products might be considered ‘natural', this does not necessarily mean they are safe. Some herbs are toxic and should not be taken at all, or some only under the supervision of a physician (Asher and colleagues, 2001). Herbal products are often defined as food products by governments and do not receive the same level of scrutiny as pharmaceutical medicines in terms of proven safety before being made available (Asher et al, 2001). Supplements may be contraindicated for some people with particular medical conditions or are incompatible with other medicines. For these reasons you should always consult your GP or medical specialist before deciding to take any substance, and should seek advice on dosage. T'ai Chi Hain (1999) found T'ai Chi gave significant benefit to people with mild balance disorders, although the small number of patients studied had balance disorders that were constant and stable (that is, they did not vary with the season or month). Ginkgo biloba extract The Asher and colleagues (2001) review paper outlines how ginkgo biloba, and its active ingredient EGb 761 in extract form, has been used in Chinese medicine for centuries. It is believed to enhance blood flow and increase circulation by reducing blood viscosity or its resistance to flow (Asher and colleagues, 2001; Sokolova and colleagues, 2014). Asher and colleagues (2001) admit that opinions differ to the efficacy of this remedy in vertigo and share the experience of their patients by stating that some patients 'swear by it' and others say 'it has no effect'. They report claims to its effect in vertigo and tinnitus (ringing in the ears) in research studies (Asher and colleagues, 2001), but it should be noted that since this article in 2001 there is now considered to be overwhelming evidence that ginkgo biloba plays no role in the alleviation of tinnitus, for example (Karkos and colleagues, 2007). The studies quoted as supporting the effectiveness of ginkgo biloba are small in number and often not of high quality. For example, Sokolova and colleagues (2014) claim ginkgo biloba is at least equally beneficial as betahistine (a drug commonly used in vertigo and dizziness) but this is a very poorly designed study with no comparison to a group of patients receiving just a placebo (non-active, sugar) pill. The authors acknowledge that there was no control (non-treatment) group taking just placebo to check that the patients would not have just improved anyway with time (which can often be the case in vertigo and dizziness). They did not acknowledge that betahistine might be considered more effective specifically in Meniere's Disease, and so might be expected to perform less optimally in a group of generally 'dizzy' patients of unknown diagnosis as in this study. The study only tests a very small number of individuals and the authors acknowledge that this means they are not able to determine any statistical significance of their findings. They claim the ginkgo biloba was tolerated slightly better than betahistine by patients, although betahistine was also well tolerated. But they provide very limited information on any adverse reactions that occurred and no statistical analysis to back up this claim. Sokolova and colleagues (2014) cite the Hamann (2007) article as proof of the effectiveness of ginkgo biloba, although the Hamann paper is a review of the literature rather than a research study in itself. Hamann (2007) does provide details of some studies reporting positive effects of ginkgo biloba when compared to placebo in animals (Denise and Bustany, 1989; MacLennan and colleagues, 1995) and humans (Claussen and colleagues, 1985; Haguenauer and colleagues, 1986). He particularly cites articles that suggest that ginkgo biloba might enhance the results of vestibular rehabilitation exercises when used as an additional treatment (Hamann, 1985; Heide and colleagues, 1998). Unfortunately these studies are mostly unavailable to me to check their quality due to being in foreign language journals or books I am not easily able to source. Because Ginkgo biloba has anti-platelet effects (platelets are components of the blood that stop bleeding), it may cause bleeding problems or increased risk of bleeding (Asher and colleagues, 2001). For this reason it may be contraindicated in patients taking anti-clotting drugs, such as warfarin, due to a risk of haemorrhage (Asher and colleagues, 2001). There is also a need to be cautious due to a probable wide variation in active ingredients in herbal preparations (Asher and colleagues, 2001). Asher and colleagues (2001) state that, in their experience, lesser known and less expensive preparations of EGb extract were more likely to result in gastrointestinal tract upset and a lesser positive benefit reported by patients. Ginger Ginger has long been used for nausea, indigestion, vomiting and motion sickness (Asher and colleagues, 2001; NHS Choices, 2015). Ernst and Pitter (2000) report ginger as favoured over placebo in one study for each of: seasickness, morning sickness, and chemotherapy-induced nausea. The Natural Medicines Comprehensive Database rates effectiveness based on scientific evidence according to the following scale: Effective, Likely Effective, Possibly Effective, Possibly Ineffective, Likely Ineffective, Ineffective, and Insufficient Evidence to Rate. Ginger is rated as ‘possibly effective' for reducing the symptoms of dizziness, including nausea (Medline Plus, 2015). NHS Choices (2015) reports despite its long term use against nausea there is little scientific evidence to support the use of ginger in motion sickness. Walko (2015) summarises the evidence for the use of ginger in chemotherapy patients experiencing nausea, and concludes that given the limited data that from an evidence-based medicine perspective it would not be recommended. However, she states her opinion that if patients do not have medical conditions that contraindicate its use, chemotherapy patients who wish to incorporate ginger into their preventative treatment may be able to do so without harmful effects, after understanding the potential risks and benefits. Few side effects are linked to ginger when it is taken in small doses. It has been rated as ‘likely safe' for most people (Medline Plus, 2015). Side effects most often reported are gas, bloating, heartburn, diarrhoea, general stomach discomfort and nausea (Medline Plus, 2015). These effects are most often associated with powdered ginger (NHS Choices, 2015). Asher and colleagues (2001) report the most common side effect as heartburn, when ginger is taken in large doses on an empty stomach. Some women have reported extra menstrual bleeding while taking ginger (Medline Plus, 2015). There is a lack of available studies that confirm the long-term, safe use of ginger supplements. The active ingredient in ginger may increase the risk of bleeding so care should be taken in individuals taking blood-thinning medications such as aspirin, anti-coagulants such as warfarin, anti-platelet drugs such as clopidogrel, and non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen. Ginger may lower blood glucose levels which might be unwanted, especially in patients with pre-existing hypoglycaemia. Ginger may interfere with medications that change the contraction of the heart, including beta-blockers and digoxin. It is thought to be best avoided if breast-feeding. Its use for nausea in pregnancy seems to remain controversial and so medical advice should be sought in this case. Caution is advised in any patients with bleeding disorders, heart conditions, or diabetes, and those who are breast-feeding (Memorial Sloan Kettering Cancer Center, 2015). Vertigoheel Vertigoheel is a homeopathic remedy using four active ingredients. The reviews of complementary medicine in Ear, Nose and Throat claim that there is some evidence that Vertigoheel might be helpful and reference a study by Weiser and colleagues carried out in 1998 (Asher and colleagues, 2001; Karkos and colleagues, 2007). This trial by Weiser and colleagues, however, only tested 12 patients, had no comparison to a placebo (comparing Vertigoheel to betahistine, ginkgo biloba and dimenhydrinate), and was published by the manufacturers of the remedy. In this way, the findings of Weiser and colleagues (1998) should be treated with upmost caution if not dismissed entirely. The number of participants in the study is too small to draw any valid statistical conclusions, any improvement seen may have occurred over time without any treatment, it compares Vertigoheel to other substances that are not necessarily proven as effective in a 'general' group of vertigo or dizzy patients, and the study is subject to bias as published by individuals with a financial interest in its success. Karkos and colleagues (2007) do admit that larger trials are needed, and that any larger studies of homeopathic treatments generally to date have concluded that any effects may be due to the placebo effect (the effect where patients improve because they are expecting their condition to improve, for example when taking empty non-active sugar [placebo] pills that they believe to contain medicine). Similarly the meta-analysis of four studies by Schneider and colleagues (2005) does not present a convincing argument for the effectiveness of Vertigoheel. Two of the four studies are observational studies only and would be considered very poor evidence. Again Vertigoheel is only compared to ‘usual' treatments (betahistine, ginkgo biloba extract, and dimenhydrinate) and found 'not inferior to these other treatments'. But these 'usual' treatments are not necessarily proven in a mixed group of vertigo patients themselves and there is no comparison to a placebo only group. I am not aware of any of my patients being prescribed dimenhydrinate for vertigo or dizziness in the UK in my practice as a Clinical Scientist in Audiology over the last 15 years. I believe it is a drug that may have been used more in the 1970s as an anti-nausea drug, and is possibly more often used abroad. Issing and colleagues (2005) again compared Vertigoheel to ginkgo biloba and made no comparison to a placebo group. This study was carried out in a very specific group of patients thought to have artherosclerosis related vertigo, which means it does not necessarily transfer to individuals experiencing vertigo or dizziness due to other reasons. Again they concluded that Vertigoheel was 'not inferior' to ginkgo biloba but did not report whether any improvement in vertigo was statistically significant. Potential side effects of Vertigoheel have been reported as nausea or tremor in less than 1% of cases when recommended doses are used (Weiser and colleagues, 1998; Asher and colleagues, 2001). Potential side effects of high doses are reported as headache, dizziness, nausea and vomiting, sleepiness, and tonic-clonic spasms (involuntary muscle spasms) (Asher and colleagues, 2001). Vertigoheel contains ingredients that should not be used if an individual is taking other GABA-ergic agents or drugs (drugs that affect the GABA system in the body) (Asher and colleagues, 2001), which includes some sedatives, tranquillizers and anticonvulsants (to include gabapentin, vigabatrin, tiagabine, lamotrigine and pregabalin, for example). Acupressure Alessandrini and colleagues (2012) claim a significant improvement of neuro-vegetative symptoms (for example, nausea and vomiting), but not vertigo, using an acupressure device placed at a location called 'point P6' near the wrist (compared to the device placed inappropriately). Deng and colleagues (2014), however, responded to this study by pointing out that Allessandrini and colleagues describe the P6 location incorrectly, putting into question whether the treatment group had an appropriately placed acupressure device after all. NHS Choices (2015) reports some claims that acupressure bands worn around the wrists can help treat motion sickness but states there is little scientific evidence to show they are effective. Other treatments Some therapies that might have initially been considered as complementary but have been accepted into the medical community for some types of dizziness are relaxation exercises if anxiety is considered to be contributing to symptoms or has become a consequence of symptoms, and breathing control exercises if an underlying breathing pattern disruption is causing dizziness. Mindfulness, which has its roots in non-Western traditions but is now accepted in conventional medicine, has been proven to help with stress, anxiety and depression, problems which can all accompany dizziness. It has also been proven helpful in chronic conditions such as chronic pain, and in the future might be found to be helpful for people experiencing chronic dizziness. There is emerging evidence in the academic literature to suggest that Vitamin D3 may be helpful in the treatment of difficult to manage Benign Paroxysmal Positional Vertigo, a particular inner ear related balance disorder. The basis of this is thought to be related to the role of Vitamin D in calcium regulation and a presumed difficulty with absorption of calcium crystals in BPPV patients (see the information I have provided from the Meniere's Society on dizziness conditions). Disclaimer –The British Society of Audiology has tries to ensure that the information provided is accurate, but does not accept and liability for any consequence of any of the use of this information. The BSA is not responsible for any claims arising from using this information. Any information is provided in good will by the British Society of Audiology but should not replace the advice from a knowledgeable practitioner who has further information about your circumstances. We cannot comment about your personal clinical management but are able to provide you with further sources of information, where appropriate, although we assume no responsibility for the content of linked websites. Any further actions required by BSA or comments of note to BSA Council: No further actions or comments, but references added in case of further query. References Adamec I et al. Incidence, seasonality and comorbidity in vestibular neuritis. Neurol Sci, 2015; 36: 91-5. Alessandrini M et al. P6 acupressure effectiveness on acute vertiginous patients: a double blind randomized study. J Altern Complement Med, 2012; 18: 1121-6. Asher BF et al. Complementary and alternative medicine in otolaryngology. The Laryngoscope, 2001; 111: 1383-9. Baloh RW. Clinical Practice. Vestibular Neuritis. New England Journal of Medicine, 2003; 348: 1027-32. Bilecki MM et al. Seasonality in vestibular disorders. International Tinnitus Journal, 2005; 11: 185-8. Buki B et al. Vitamin D deficiency and benign paroxysmal positioning vertigo. Med Hypotheses, 2013. 80: 201-4. Celestino D et al. Seasonal recurrence of acute episodes of Meniere's disease. Acta Oto-rhino-laryngologica Belgica, 1987; 41: 951-7. Cicetti F. Does ginger help with nausea?3/10/2015. Claussen CF et al. Doppelblindstudie zur Wirkung von Extractum Ginkgo biloba bei Schwindel und Gangunsicherheit des älteren Menschen. In: Claussen CF (ed.) Presyvertigo, Presbyataxie, Presbytinnitus. Berlin: Springer; 1985. pp. 103-15. Deng S-Z et al. P6 acupressure effectiveness in patients with acute vertigo. The Journal of Alternative and Complementary Medicine, 2014; 20: 69-70. Denise P, Bustany P. The effect of extract of Ginkgo biloba (EGb 761®) on central compensation of a total unilateral peripheral vestibular deficit in the rat. In: Lacour M, Toupet M, Denise P, Christen Y (eds). Vestibular compensation: facts, theories and clinical perspectives. Paris: Elsevier; 1989. pp. 201-8. Ernst E, Pitter MH. Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials. Br J Anesth, 2000; 84: 367-71. Haguenauer JP et al. Traitement des troubles de l'équlibre par l'extrait de Ginkgo biloba. Presse Med, 1986; 15: 1569-72. Hain TC et al. Effects of T'ai Chi on balance. Arch Otolaryngol Head Neck Surg, 1999; 125: 1191-5. Hain T. Seasonal vertigo13/10/2015. Hamann KF. Physikalische Therapie des vestibulären Schwindels in Verbindung mit Ginkgo-biloba-Extrakt. Therapiewoche, 1985; 35: 4586-90. Hamann K. Ginkgo special extract EGb 761 in vertigo: a systematic review of randomised, double-blind, placebo-controlled clinical trials. Internet Journal of Otorhinolaryngology, 2007; 6: 258-63. Heide W et al. Schwindel und Nystagmus bei zentral-vestibulären Ischämien: eine Placebokontrollierte Therapiestudie mit Ginkgo-biloba-Extrakt EGb761®. Aktuelle Neurologie, 1998; 25 (suppl. 3): S94. Issing W et al. The homeopathic preparation Vertigoheel versus Gingko biloba in the treatment of vertigo in an elderly population: a double-blinded, randomized, controlled clinical trial. Journal of Alternative and Complementary Medicine, 2005; 11: 155-60. Jeong SH et al. Decreased serum Vitamin D in idiopathic benign paroxysmal positional vertigo. J Neurol, 2013. 260: 832-8. Karkos PD et al. ‘Complementary ENT': a systematic review of commonly used supplements. The Journal of Otolaryngology and Otology, 2007; 121: 779-82. Koors PD et al. Investigation of seasonal variability of vestibular neuronitis. The Journal of Laryngology and Otology, 2013; 127: 968-71. Lai Y-T et al. Epidemiology of vertigo: a national survey. Otolaryngolo Head Neck Surg, 2011; 145: 110-16. Maclennan K, Smith PF, Darlington CL. Ginkgolide B accelerates vestibular compensation of spontaneous ocular nystagmus in guinea pig following unilateral labyrinthectomy. Exp Neurol, 1995; 131: 273-8. Mariani P et al. Epidemiology of paroxysmal positioning vertigo: correlation with seasons, climate, and pollution. International Tinnitus Journal, 2008; 14: 168-74. Medline Plus. Ging13/10/2015. Memorial Sloan Kettering Cancer Cent3/10/2015. Meniere's Society. Dizziness and Balance. 2015. Meniere's Society. Let's Talk Friday – Weather. 05/06/2015. NHS Cho3/10/2015. Pereira AB et al. Seasonality of dizziness and vertigo in a tropical region. Chronobiology International, 2015; 32: 585-90. Ryan C. Seasonal vertigo sufferers can predict weather chang3/10/2015. Schneider B et al. Treatment of vertigo with a homeopathic complex remedy compared with usual treatments: a meta-analysis of clinical trials. Arzneimittelforschung, 2005; 55: 23-9. Siddiqui IA et al. Epidemiology of vestibular neurinitis in vertigo presenting at tertiary care health care facility in Pakistan. Pak J Med Sci, 2011; 27: 427-9. Sokolova L et al. Treatment of vertigo: a randomized, double-blind trial comparing efficacy and safety of gingko biloba extract EGb 761 and betahistine. International Journal of Otolaryngology, 2014; 2014:682439. doi: 10.1155/2014/682439. Talaat HS et al. Low bone mineral density and vitamin D deficiency in patients with benign paroxysmal vertigo. Eur Arch Otorhinolaryngol, 2014. June 29. Yamanaka T et al. Osteoporosis as a risk factor for the recurrence of benign paroxysmal positional vertigo. Laryngoscope, 2013. 123: 2813-6. Walko CM. Ginger for preventing chemo-induced nausea: what is the evidence? 13/10/2015. Weiser et al. Homeopathic vs conventional treatment of vertigo: a randomized double-blind controlled clinical study. Arch Otolaryngology Head Neck Surg, 1998; 124: 879-85.

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