Vitamin D and BPPV: Should We Be Thinking Beyond the Repositioning Manoeuvre?

Benign paroxysmal positional vertigo (BPPV) is something vestibular clinicians see every day. We identify the affected canal, determine the likely mechanism and perform the appropriate repositioning manoeuvre.

For many patients, this works remarkably well.

But what about the patient who keeps coming back?

Recurrent BPPV is common, and over recent years there has been growing interest in whether we should be looking beyond the semicircular canals and considering some of the systemic factors that may influence the health and stability of the otoconia.

One factor receiving increasing attention is vitamin D.

Why might vitamin D be related to BPPV?

BPPV occurs when otoconia become displaced from the utricle and enter a semicircular canal or become attached to the cupula.

Otoconia are small calcium carbonate structures. Their formation, maintenance and turnover are therefore closely related to calcium homeostasis and biomineralisation.

Vitamin D plays an important role in calcium metabolism and bone mineralisation. This has led researchers to propose that low vitamin D may affect the integrity, formation or turnover of otoconia, potentially making them more susceptible to degeneration or detachment.

There are also recognised associations between BPPV and osteoporosis or reduced bone mineral density, providing further support for a possible relationship between systemic calcium metabolism and otoconial health.

The proposed pathway is therefore broadly:

Low vitamin D → altered calcium homeostasis and biomineralisation → impaired otoconial health → increased susceptibility to otoconial detachment → BPPV.

This remains a proposed biological mechanism rather than a completely established causal pathway. However, the clinical evidence linking vitamin D and BPPV has become increasingly interesting.

What does the evidence tell us?

A 2024 systematic review and meta-analysis by Wood, Kluk and BinKhamis examined 35 studies involving 9,843 participants. Serum vitamin D levels were, on average, lower in people with BPPV compared with controls. However, their analysis found that the relationship between vitamin D levels and recurrent versus non-recurrent BPPV remained uncertain, highlighting variability in the available evidence.

More recently, Li and colleagues published a much larger systematic review and meta-analysis involving 60 studies and 16,368 participants. They found significantly lower vitamin D levels both in people with BPPV compared with controls and in people with recurrent BPPV compared with those without recurrence. Their analysis also supported a reduction in recurrence associated with vitamin D supplementation.

Importantly, however, association does not necessarily demonstrate causation. Low vitamin D could potentially be associated with other factors influencing BPPV risk, and there is considerable heterogeneity across studies.

This is why the supplementation studies are particularly important.

Can correcting low vitamin D reduce BPPV recurrence?

This is perhaps the most clinically relevant question.

Jeong, Lee and Kim (2022) performed a meta-analysis specifically examining vitamin D supplementation for the prevention of recurrent BPPV. Five trials involving 1,250 participants were included. Vitamin D supplementation, either alone or with calcium, was associated with a significant reduction in recurrence, with a pooled relative risk of 0.37 (95% CI 0.18–0.76). The authors concluded that vitamin D supplementation may have a role in secondary prevention, particularly in people with frequent BPPV and subnormal serum vitamin D.

This finding has subsequently been supported by further research.

Kong and colleagues (2024) conducted a prospective, double-blind, placebo-controlled randomised trial in people with BPPV and serum 25-hydroxyvitamin D levels below 20 ng/mL. Following successful canalith repositioning, participants received either vitamin D or placebo. Recurrence was lower in the vitamin D group during follow-up. It is worth noting that this was a small study, with only 38 participants randomised, so the findings should be interpreted in that context.

The 2025 meta-analysis by Li and colleagues subsequently incorporated a much larger body of evidence. Thirteen supplementation studies involving 1,714 participants were included in the supplementation analysis, further supporting a protective effect of vitamin D supplementation against BPPV recurrence.

More recently again, a 2026 prospective, randomised, double-blind, placebo-controlled trial investigated vitamin D supplementation in people with BPPV and concurrent vitamin D deficiency, adding further randomised evidence to this evolving area.

Taken together, the evidence is increasingly pointing in the same direction: in people with BPPV who are vitamin D deficient, correcting that deficiency may reduce the risk of future BPPV episodes.

This doesn't change how we treat acute BPPV

There is an important distinction here.

Vitamin D is not a substitute for repositioning manoeuvres.

If someone presents with posterior canal BPPV, for example, our immediate task remains to establish the diagnosis, identify the affected side and mechanism, and perform an appropriate canalith repositioning manoeuvre.

Vitamin D supplementation does not reposition displaced otoconia.

Instead, we should think about two different components of management:

Treat the current episode:
Identify the canal and mechanism → perform the appropriate repositioning manoeuvre.

Consider recurrence prevention:
In recurrent BPPV → consider contributing factors → identify vitamin D deficiency where appropriate → ensure deficiency is appropriately managed.

When should vestibular clinicians think about vitamin D?

This does not necessarily mean that every person experiencing their first episode of uncomplicated BPPV requires extensive blood testing.

However, recurrent BPPV should make us think more broadly.

In someone experiencing repeated apparently idiopathic episodes, particularly where other risk factors for vitamin D deficiency or poor bone health are present, checking serum 25-hydroxyvitamin D may be reasonable as part of broader medical management.

Many of the supplementation studies have specifically focused on people with vitamin D deficiency, commonly defined in these studies as serum 25-hydroxyvitamin D below 20 ng/mL (50 nmol/L).

This distinction is important. The current evidence should not be interpreted as demonstrating that everyone with BPPV should simply start taking vitamin D supplements regardless of their serum level.

Rather, the strongest clinical argument is:

Recurrent BPPV + demonstrated vitamin D deficiency → consider correction of the deficiency as part of recurrence prevention.

The assessment and treatment of vitamin D deficiency should, of course, sit within appropriate medical care and take account of the individual's broader health, medications, calcium status and other relevant factors.

Thinking beyond the crystals

Perhaps the most interesting aspect of this research is that it encourages us to think differently about BPPV.

BPPV is clearly a mechanical vestibular disorder. The symptoms occur because displaced otoconia interact abnormally with the mechanics of the semicircular canals or cupula.

But why did those otoconia become displaced in the first place?

For some people the answer may be trauma, another vestibular disorder or another identifiable event. For many others, BPPV remains classified as idiopathic.

Increasing evidence around vitamin D, calcium metabolism and bone health raises the possibility that, at least in some people, recurrent BPPV may represent the downstream vestibular consequence of altered otoconial health and mineral metabolism.

That doesn't make the repositioning manoeuvre any less important.

It simply means that when someone repeatedly returns with BPPV, our clinical reasoning perhaps shouldn't finish once the Dix-Hallpike is negative.

Sometimes we need to think beyond the crystals — and ask why they keep coming loose.

References

Jeong, S. H., Lee, S. U., & Kim, J. S. (2022). Prevention of recurrent benign paroxysmal positional vertigo with vitamin D supplementation: A meta-analysis. Journal of Neurology, 269(2), 619–626. https://doi.org/10.1007/s00415-020-09952-8

Kong, T. H., Jung, S. Y., Seo, Y. J., & Shim, D. B. (2024). Vitamin D supplementation in preventing the recurrence of benign paroxysmal positional vertigo. Laryngoscope Investigative Otolaryngology, 9(1), e1225. https://doi.org/10.1002/lio2.1225

Li, Y., Gao, P., Ding, R., Xu, Y., Wang, Z., Pei, X., & Li, L. (2025). Association between vitamin D, vitamin D supplementation and benign paroxysmal positional vertigo: A systematic review and meta-analysis. Frontiers in Neurology, 16, 1560616. https://doi.org/10.3389/fneur.2025.1560616

Tawfeeq, H. A., Zaidan, M. A., & Ghanim, A. K. (2026). Vitamin D supplementation for preventing recurrent benign paroxysmal positional vertigo: A randomized clinical study. Annals of Otology, Rhinology & Laryngology, 135(9), 720–727. https://doi.org/10.1177/00034894261449743

Wood, H., Kluk, K., & BinKhamis, G. (2024). Association between vitamin D deficiency and benign paroxysmal positional vertigo (BPPV) incidence and recurrence: A systematic review and meta-analysis. BMJ Open, 14(4), e077986. https://doi.org/10.1136/bmjopen-2023-077986 

Associate Professor James McLoughlin