Vertigo and BPPV: Independent Evidence on Epley, Drugs & Funding

Table of contents

• Evidence summary
• What vertigo and BPPV are
• Symptoms, red flags and the HINTS exam
• Causes and risk factors
• Treatments that work, and those that do not
• Medicines
• Supplements and lifestyle claims
• Risks, falls and driving
• Who to see
• Follow the money: who makes it and who funded the evidence
• Related research
• Frequently asked questions
• Sources and funding notes

Evidence summary

Independent evidence and credibility scorecard

Independence tiers: 1 = regulator or government body; 2 = academic or Cochrane team with no declared commercial funding for the work; 3 = professional societies, or trial teams with declared manufacturer payments or contracts; 4 = manufacturer-authored. Credibility runs from A (highest) to D. We treat specialist societies as tier 3 because their members earn a living from treating these patients. Sources cluster in the UK, US, Germany and Australia, and the drug-trial evidence leans heavily on one German vertigo centre.

What vertigo and BPPV are

Vertigo is the false sense that you or the room is spinning or moving. The NHS lists the main causes as BPPV, labyrinthitis (an inner ear infection, usually after a cold or flu), vestibular neuritis (inflammation of the balance nerve) and Ménière's disease. Migraine and some medicines can also trigger it, and sometimes no cause is found (NHS: Vertigo).

BPPV causes repeated, short episodes of positional vertigo. It is the subject of a US specialist guideline for adults (AAO-HNSF 2017). The guideline defines the common rear-canal form by vertigo with a particular twisting, upward-beating eye movement (nystagmus) that is provoked by the Dix-Hallpike test. In this test a clinician moves your head and body into a set position while watching your eyes.

The balance organ is a set of fluid-filled canals and sensors in the inner ear. We did not find a source we could open for the full mechanism of BPPV, so we do not describe it beyond what the guideline and Cochrane review state: the treatments are "repositioning" procedures, which are a series of head and body movements done by a trained clinician (Cochrane 2014).

Symptoms, red flags and the HINTS exam

Peripheral and central vertigo

Doctors split causes into peripheral (the inner ear or its nerve) and central (brainstem or cerebellum, most worryingly from stroke). Most vertigo is peripheral. The NHS says vertigo often gets better without treatment, and that urgent help is needed when it comes with double vision, vision or hearing loss, speech trouble, or limb weakness or numbness (NHS).

What HINTS is, and what it can and cannot do

HINTS stands for Head Impulse, Nystagmus and Test of Skew: three bedside eye-movement checks. The 2009 study that introduced it enrolled 101 high-risk patients with acute vestibular syndrome (sudden, ongoing vertigo). Of these, 25 had a peripheral lesion and 76 a central one, including 69 ischaemic strokes. A dangerous HINTS pattern was 100% sensitive and 96% specific for a central lesion (positive likelihood ratio 25, 95% CI 3.66 to 170.59). It outperformed early MRI, which was falsely negative in 12% of patients, all scanned within 48 hours (Kattah et al. 2009).

Real-world accuracy is lower. The 2023 Cochrane review included 16 studies (2,024 people; 13 in emergency departments, about half examined by neurologists). For clinical HINTS (12 studies, 1,890 people) the review found sensitivity 94.0% (82.0 to 98.2) and specificity 86.9% (75.3 to 93.6), with low certainty. Adding a bedside hearing test ("HINTS Plus", 5 studies, 451 people) gave 95.3% sensitivity (78.4 to 99.1) but only 72.9% specificity (44.4 to 90.1). The authors concluded the exam has "good sensitivity and reasonable specificity" when trained clinicians use it in the emergency department, and called for more high-quality studies (Gottlieb et al. 2023).

What this means for readers: a normal result from a trained examiner lowers the chance of stroke but does not rule it out, and the exam says nothing useful about BPPV, whose attacks are brief and triggered by head position. The test belongs to emergency clinicians. It is not something to try on yourself or a relative.

Causes and risk factors

Ménière's disease

The AAO-HNS defines Ménière's disease as spontaneous vertigo attacks lasting about 20 minutes to 12 hours, with low- to mid-frequency hearing loss in the affected ear and often tinnitus or ear fullness. It is linked to excess inner ear fluid, but the cause is not fully understood (AAO-HNS guideline 2020). The NHS describes episodes lasting minutes to 24 hours, with hearing that can slowly worsen and tinnitus that can become constant (NHS: Ménière's disease).

Vestibular migraine and the overlap with Ménière's

Vestibular migraine is vertigo or head-motion dizziness linked to migraine. The Bárány Society and International Headache Society criteria require recurrent moderate or severe vestibular symptoms lasting between 5 minutes and 72 hours, a history of migraine, a timing link with migraine features, and no better explanation (Lempert et al. 2022). A narrative review estimates its prevalence at 1% to 5% and lists Ménière's disease, BPPV and episodic ataxia as look-alikes (Vlastarakos et al. 2025). The duration windows overlap: a 3-hour attack could fit either condition. Hearing loss and ear fullness point towards Ménière's; migraine history and sensitivity to light or sound towards migraine. Telling them apart is a specialist task, and some people have both.

Risk factors

We did not find a source we could open that quantifies the risk factors for BPPV (such as age or head injury), so we do not list any. The AAO-HNSF guideline does advise clinicians to look for factors that change management, including impaired mobility or balance, central nervous system disorders, lack of home support and fall risk (AAO-HNSF 2017).

Treatments that work, and those that do not

How the Epley manoeuvre works in practice

The Cochrane plain-language summary describes it as four movements of the head and body, from sitting to lying, rolling over and back to sitting, done by a trained health professional (Cochrane 2014). We do not give step-by-step instructions, because the manoeuvre should follow a diagnosis of the correct canal and side.

Medicines

Betahistine for Ménière's disease

The best trial. BEMED was a double-blind, placebo-controlled, three-arm trial at 14 German referral centres. It randomised 221 adults aged 21 to 80 with definite Ménière's disease to placebo (74), 2 x 24 mg betahistine daily (73) or 3 x 48 mg daily (74) for nine months. The primary outcome was attacks per 30 days in months 7 to 9. There was no difference (P=0.759). Rate ratios against placebo were 1.036 (95% CI 0.942 to 1.140) for the low dose and 1.012 (0.919 to 1.114) for the high dose, while attacks fell overall by a factor of 0.758 (0.705 to 0.816). The authors note that with no untreated group, they could not separate the placebo effect from natural remission (Adrion et al. 2016).

Safety signals in BEMED. More than 85% of patients had at least one treatment-emergent adverse event, with no clinically relevant difference between groups. Balance disorder and nausea were somewhat more frequent on betahistine, and eye irritation and palpitations more frequent at the high dose; the authors judged these small (BEMED full text).

The wider evidence. The 2023 Cochrane review of medicines for Ménière's disease found 10 randomised or quasi-randomised trials (848 participants). Seven were of betahistine (548 participants), and no pooled analysis of the main outcomes was possible. Its conclusion was that the evidence is "very uncertain" (Webster et al. 2023).

Why people still use it. The US specialist guideline gives betahistine and diuretics a weak "option" rating for maintenance therapy (Guideline Central summary). The UK label says it is for "vertigo, tinnitus and hearing loss associated with Ménière's syndrome", with adult maintenance doses generally 24 to 48 mg a day (UK label). The same label says it is contraindicated in phaeochromocytoma, calls for caution in people with a history of peptic ulcer or bronchial asthma, and advises avoiding it in pregnancy where possible. Common side effects are nausea, indigestion and headache (UK label). The NHS Ménière's page does not mention betahistine (NHS).

Anti-dizziness (vestibular suppressant) drugs

The AAO-HNSF guideline recommends against routine use of vestibular suppressants such as antihistamines or benzodiazepines for BPPV (AAO-HNSF 2017). The NHS says antihistamines can sometimes help vertigo in general (NHS). The two statements fit together: these drugs may dampen the sensation, but they do not fix BPPV, which is why the guideline prefers a repositioning procedure.

Preventing vestibular migraine attacks

The 2023 Cochrane review found only 3 trials (209 participants): one of metoprolol and two of flunarizine, with low or very low certainty and no other drugs studied. The metoprolol trial (PROVEMIG) randomised 130 people of a planned 266 to metoprolol succinate 95 mg daily or placebo for six months. Attack rates did not differ (rate ratio 0.983, 95% CI 0.902 to 1.071), and it stopped early because of poor recruitment and lack of funding (PROVEMIG; Cochrane 2023). A 2026 narrative review of antibody drugs targeting CGRP, a migraine signalling molecule, found eight mostly small, unblinded studies and one randomised trial, and said the evidence is limited (Tarnutzer et al. 2026). Migraine drugs may still be used on expert advice, but this is mostly off-label practice rather than trial-proven.

Supplements and lifestyle claims

Risks, falls and driving

Other risks

• Missed central cause: sudden, ongoing vertigo with red flags is a medical emergency until stroke is excluded. Even early MRI can miss it (Kattah 2009).
• Treatment side effects: nausea during the Epley manoeuvre in 16.7% to 32% of patients; vomiting was reported in one trial; some people cannot tolerate it because of cervical spine problems (Cochrane 2014).
• Falls and safety: the guideline tells clinicians to educate patients about the safety impact of BPPV, and to check mobility, balance and fall risk (AAO-HNSF 2017).
• Betahistine: see the label cautions above (UK label). In studies designed to test driving, the label says betahistine had no or negligible effect on driving ability, though the condition itself can impair it.

Who to see

• Emergency services: for the red flags in the callout above (NHS).
• A GP: for vertigo that will not go away or keeps coming back (NHS).
• A clinician trained in repositioning: the guideline says to treat rear-canal BPPV with a repositioning procedure "or refer" to someone who can, and to reassess within a month. It also advises evaluating persistent symptoms for unresolved BPPV or another inner ear or brain cause (AAO-HNSF 2017).
• Ear specialists, audiology and vestibular therapists: for suspected Ménière's disease, hearing loss, or lasting imbalance. The NHS lists hearing aids, tinnitus therapies and vestibular rehabilitation for Ménière's disease (NHS).

Follow the money: who makes it and who funded the evidence

Who sells the treatments

• Betahistine brands: Abbott's own medicines site lists betahistine under brand names including Serc and Vertin, and notes that names and approved uses vary by country. We could not open that page, so we rely on the facts below that we could read. In the UK, the Serc product's licence holder is Viatris Products Limited (UK label for Serc), and unbranded betahistine tablets are sold by several companies, for example Amarox Limited (UK label, Amarox).
• Ownership trail: the Cochrane review's references show a Solvay Pharmaceuticals trial report "supplied by Abbott Healthcare" (Webster 2023). Abbott, based in Illinois, US, completed a EUR 4.5 billion (about $6.2 billion) acquisition of Solvay's pharmaceutical business on 15 February 2010 (Abbott SEC filing). We could not open a source that traces each brand's later transfers between companies, so we do not claim one.
• Repositioning and rehabilitation: delivered by NHS and private clinicians. Epley is a manual technique, so there is no product behind it. We did not research the market for balance-testing equipment or vestibular therapy apps.

Who funded the trials

• Public money: BEMED was supported by the German Federal Ministry of Education and Research (support code 01KG0708) and the German Centre for Vertigo and Balance Disorders. It states the trial was not industry sponsored, and the funder had no role in design, analysis or reporting (BEMED). PROVEMIG was funded through the same vertigo centre, itself funded by the ministry (PROVEMIG). The Cochrane reviews by Webster and colleagues were funded by the NIHR, which says it is funded by the Department of Health and Social Care (NIHR via INAHTA). The original HINTS study was supported by US NIH and AHRQ grants (Kattah 2009).
• Manufacturer-funded or supplied (older betahistine and related trials): in the Cochrane review's table of included studies, one trial was "Funded by Duphar Laboratories", one was supported by a grant from Grünenthal-Formenti, and one had active drug and placebo supplied by Novartis. A thesis was published with support from Entermed BV, Duphar Nederland BV and Astra Pharmaceutica BV. We did not map every funder to its drug, and several records give no funding or no declaration (Webster 2023). We treat these as manufacturer-funded and not as the basis of our conclusions.
• Commercial ties inside the independent trials: the BEMED declaration says Michael Strupp, the coordinating investigator and senior author, reported speaker honoraria from several companies including Abbott and had worked as an Abbott consultant. Christine Fischer reported travel grants from Abbott and Pierre Fabre. Abbott Healthcare Products BV supported the descriptive safety analyses, and under a contract Abbott had access to the data after the analyses were complete, with financial compensation, to support approval of betahistine for Ménière's disease. The contract was approved by the funder and university bodies, and Abbott says it had no influence on the analyses or manuscript (BEMED disclosures). Methods name Abbott as the maker of the betahistine product used. The trial still reported no benefit. Strupp's PROVEMIG declaration lists speaker honoraria and consulting for firms including Abbott, Actelion, Biogen and UCB and shares in IntraBio (PROVEMIG disclosures).
• Cochrane's own rules: the 2014 policy says Cochrane reviews cannot be funded or conducted by commercial sponsors with a vested interest in a review's findings. The page says the policy is retired from 1 October 2025 and points to newer conflict-of-interest policies (Cochrane).

Documented integrity events

• A Hearing Health Foundation article says the US FDA approved betahistine for Ménière's disease in the 1960s and withdrew the approval in 1968, citing "inconclusive evidence of efficacy and misrepresentation" (Hearing Health Foundation). That is a secondary account from a charity that funds hearing research, not an FDA record, and we could not open a primary source. Sources we saw in search results disagreed on the exact dates.
• We found no warning letters, recalls or enforcement actions against betahistine makers or repositioning providers in the sources we opened. We did not complete a search for them.

What this means: the strongest findings in this field, on repositioning, rehabilitation and the negative betahistine result, come from publicly funded or unfunded teams, and the two most commercially exposed claims, that betahistine works for Ménière's disease and that HINTS-style testing is always accurate, are the weakest. Funding does not decide any result here. The notable overlap is that one German vertigo centre and its senior investigator appear in both the largest drug trials and in declared ties to the betahistine brand owner. Independent evidence converges on the same message from different directions: repositioning works, pills are unproven.

Related research

For wider, evidence-graded context, see these Pure City Research guides:

• Stroke: emergency signs and treatment
• Transient ischaemic attack
• Carotid artery disease
• Orthostatic hypotension
• Postural orthostatic tachycardia syndrome (POTS)
• Vasovagal syncope
• Amitriptyline: independent evidence
• Panic disorder
• Cogan syndrome

Frequently asked questions

Sources and funding notes

What we could not verify: NICE pages (blocked automated access), so we did not use NICE dizziness guidance or Clinical Knowledge Summaries. The funding statement of the 2023 Cochrane HINTS review (only the abstract record and its authors were accessible; do not assume it is unfunded). The disclosure sections of the two AAO-HNS guidelines, and which of the guideline panel members have industry ties. The full text of Abbott's betahistine page and a primary FDA record of the 1968 withdrawal; we cite a charity's summary and mark it as secondary. Whether the Serc brand moved between companies after Abbott bought Solvay's pharmaceuticals business. Quantified risk factors for BPPV, a mechanism source for BPPV, and any trial of home self-treatment. Real-world driving rules specific to BPPV. A funding statement for the Bárány Society and International Headache Society criteria paper (a Europe PMC record lists UK research grants against an author, which we did not link to the work). Our Epley "1 in 3" figure is our arithmetic from the published 21% and 56%, not a published number needed to treat. One AAO-HNS web page we fetched contained embedded text telling the reader how to format a response; we ignored it and used only its factual statements.

1. NHS website. Vertigo (last reviewed 2 May 2023) — UK public health information; red flags, causes, driving.
2. NHS website. Ménière's disease (last reviewed 11 September 2026) — UK public health information.
3. GOV.UK. Neurological disorders: assessing fitness to drive — UK government (DVLA).
4. Hilton MP, Pinder DK. The Epley manoeuvre for BPPV. Cochrane 2014 (full text) — systematic review; no support listed, authors declare none.
5. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane 2015 (full text) — systematic review; internal support University of South Australia centre.
6. Gottlieb M, Peksa GD, Carlson JN. HINTS for central causes of acute vestibular syndrome. Cochrane 2023 — diagnostic accuracy review; funding statement not opened.
7. Kattah JC et al. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke 2009 (full text) — diagnostic study; US NIH and AHRQ; no conflicts declared.
8. Bhattacharyya N et al. Clinical practice guideline: BPPV (update). Otolaryngol Head Neck Surg 2017 — US specialist society guideline; no funder in record.
9. Basura GJ et al. Clinical practice guideline: Ménière's disease. 2020; Guideline Central summary; AAO-HNS guideline page — US specialist society; funded by AAO-HNS per record; summary site is a commercial secondary source.
10. Adrion C et al. Efficacy and safety of betahistine in Ménière's disease (BEMED). BMJ 2016 (full text) — German federal ministry and vertigo centre; declared Abbott ties and data-access contract.
11. Webster KE et al. Systemic pharmacological interventions for Ménière's disease. Cochrane 2023 (full text) — NIHR.
12. Webster KE et al. Lifestyle and dietary interventions for Ménière's disease. Cochrane 2023 and Hussain K et al. Restriction of salt, caffeine and alcohol. Cochrane 2018 — NIHR grant (2023); none listed in record (2018).
13. Webster K et al. Pharmacological interventions for prophylaxis of vestibular migraine. Cochrane 2023 and PROVEMIG trial (Trials 2019) — NIHR; German federal ministry via vertigo centre; declared industry ties for the senior author.
14. Lempert T et al. Vestibular migraine: diagnostic criteria. J Vestib Res 2022 — Bárány Society and International Headache Society consensus; funding not verified.
15. Vlastarakos P et al. Vestibular migraine revisited. J Int Adv Otol 2025 and Tarnutzer AA et al. CGRP-targeted therapy in vestibular migraine. Eur J Neurol 2026 — narrative reviews; no grants listed in the records.
16. electronic Medicines Compendium. Betahistine 16 mg tablets (Amarox) and Serc-16 (Viatris) — manufacturer-written, regulator-approved labels.
17. Abbott Laboratories Form 8-K, February 2010 — company filing on the Solvay acquisition.
18. Hearing Health Foundation. A historical review of Ménière's disease treatments (2023) — US charity that funds hearing research; secondary account of the 1968 FDA withdrawal.
19. Cochrane. Commercial sponsorship policy; INAHTA. NIHR member page — funders' own descriptions of how they are funded.

Educational research reviewed 6 October 2026. This article is not medical advice; talk to a qualified clinician or pharmacist before starting, stopping or combining treatments.