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Author: admin | 10.04.2015 | Category: Relieve Tinnitus

The effect of betahistine dihydrochloride on the postural stability after repositioning Epley's maneuver (EM) in patients with BPPV was evaluated by static posturography in open and closed eyes conditions. Benign paroxysmal positional vertigo (BPPV) is the most common cause for peripheral vestibular vertigo.
The pharmacological therapies applied to BPPV patients are directed to suppress the vertigo.
The aim of the current study was to determine the effect of treatment with Betahistine dihydrochloride on the postural stability after repositioning Epley's maneuver in patients with different duration of BPPV - PSC, evaluated by static posturography.
All participants did not take antivertigo drugs, antihistamines, calcium antagonists, antiaggregants, thiazide diuretics, corticosteroids and benzodiazepines.
All patients were instructed to restrain from alcohol use and any kind of medication for 24 hours before testing. A static posturographic system designed in the Institute of Neurobiology, Sofia, was used to measure the balance ability26,27. For removal of the otoconias from posterior semicircular canal we used the repositioning maneuver described by Epley6. Postural stability of patients was evaluated before treatment, one hour after the negative Dix-Hallpike test, 10 and 20 days after the physical treatment with the EM.
The postural stability was evaluated by means of "Sway velocity" (SV) calculated for each subject and each experimental condition.
Before treatment with LM the SV of postural sways in two patient groups are significantly higher than that in healthy subjects (P P P 60 days) the deprivation of vision did not change significantly the SV of postural sways (Figure 1). The changes of patients SV in comparison with SV of healthy subjects (dotted line) is presented in Figure 2 (a-d). The SV decreased but stayed significantly higher than that in healthy subjects, most expressed in patients group above 60 days duration of BPPV (Figure 2 a-d). Therapy with Betahistine dihydrochloride helped to restore the postural stability of this patients group. The beneficial effect of the most popular liberatory maneuver of Semont5, Epley maneuver6 or Brandt- Daroff exercises7 for treating Benign Paroxysmal Postural Vertigo is well known. In conclusion, the results of this study show the dependence between efficacy of treatment with Betahistine dihydrochloride applied after EM and duration of BPPV. Symptom improvement can be noticed as early as two weeks after beginning treatment, but the best results can take up to three months.
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Effect of treatment with betahistine dihydrochloride on the postural stability in patients with different duration of benign paroxysmal positional vertigo.
Ninety patients were divided into four groups by duration (less and above 60 days of BPPV) and by treatment (with and without treatment with betahistine). The diagnosis BPPV - PSC was based on the patient's complaints of presence of episodes of transient attacks of rotational vertigo induced by sudden head movements without auditory symptoms and the positive Dix-Hallpike positioning test (inducing the typical torsional transient positioning nystagmus)2,4.
Patients with head injury, ear infection, vestibular neuritis or Meniere's disease were excluded from the investigation.
All participants signed an informed consent form following approval by the Ethic Committee of the Institute of Neurobiology, Sofia, in conformity with the Declaration of Helsinki. Briefly, the displacements of foot pressure center in both medio-lateral (ML) and anteriorposterior (AP) directions were registered. The maneuver was performed several times until the vertigo and the nystagmus disappeared - the negative Dix-Hallpike positioning test.
Static balance was measured in two conditions: (1) stance on the stable platform with open eyes (OE), targeting at a distance of 2 m at the eye's plane and (2) with closed eyes (CE). The differences between SV of two patients groups as well as between SV of patients and SV of healthy control were analyzed with Mann-Whitney test.
Ten days after treatment the SV was normalized and did not differ from that in healthy subjects (Figure 2 a-d). The therapy with Betahistine dihydrochloride used after applying Semont liberatory maneuver and Brandt-Daroff exercises demonstrated the better results evaluated by Epley criteria6 14 days after treatment, independently of age of patients17. The treatment with Betahistine dihydrochloride at a daily dose of 48 mg had beneficial effect on the 10th day after EM in BPPV with duration of disease less than 60 days of the first symptom of vertigo.


If a dose is missed, it should be taken as soon as it is remembered unless this might cause a "doubling up" of the dose. Women under the age of fifty who took this medication for twelve weeks lost up to seven times the weight of those who took a placebo, all without serious side effects. It's thought that Betaserc's properties as a histamine antagonist will act to increase bioavailability of dopamine and serotonin in the nervous system. The investigation was made one hour after the positive Dix-Hallpike test, 10 and 20 days after the treatment with EM.
BPPV is characterized by brief repeated episodes of mild to intense dizziness provoked by specific changes in the position of the head, and accompanied by imbalance, and nausea1,2. The patients with BPPV - PSC were divided into four groups depending on the duration of symptoms of vertigo and of treatment (Table 1). Two analogue signals were digitized with a sampling interval of 10 ms and filtered with a digital Hamming low-pass filter with cut-off frequency of 10 Hz in order to remove the high frequency noise and discretization error29.
The participants were informed to stand upright on the platform with separated heels of 3 cm distance and feet splayed at an angle of 30°.
A possible effect of Betahistine dihydrochloride on the postural stability of two BPPV patients groups was evaluated by repeated-measures ANOVA with four factors. Twenty days after the physical treatment without drug therapy the typical nystagmus and vertigo disappear in 71% of the patients with BPPV - PSC and a negative Dix-Hallpike test was observed, but in 96% of them the sense of postural instability persisted. The changes of SV were presented as follows: (a) and (b) the SV in medio-lateral (ML) direction, (c) and (d) the SV in anterior-posterior (AP) direction, (a) and (c) on open eyes condition and (b) and (d) on closed eyes condition. For other patients group (>60 days) the effects of all factors were not statistically significant.
In our previous study we determined the difference in the process of recovery after treatment with Eplay maneuver in patients with duration of BPPV - PSC less and more than 60 days25.
The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo.
Effects of histamine and betahistine on rat medial vestibular nucleus neurons: possible mechanism of action of anti-histaminergic drugs in vertigo and motion sickness. Betahistine, vestibular function and compensation: in vitro studies of vestibular function and plasticity. Betahistine produces post-synaptic inhibition of the excitability of the primary afferent neurons in the vestibular endorgans.
Benign paroxysmal positional vertigo: a study of two maneuvers with and without betahistine. The effects of the canalith repositioning maneuver on resolving postural instability in patients with benign paroxysmal positional vertigo.
Postural stability in patients with different duration of benign paroxysmal positional vertigo. Problem with the use of total distance traveled and average speed as measures of postural sway. Institute of Neurobiology, Department of Cognitive Psychophysiology, Bulgarian Academy of Sciences, Sofia, Bulgaria.
This medication, a histamine antagonist, dilates blood vessels in the middle ear, relieving internal pressure from excess fluids, and reducing the severity of light-headedness or vertigo. The most common hypothesis for the BPPV is the presence of small crystals of calcium carbonate, named 'otoconia', derived from the utricular and saccular macula in the semicircular canal. In addition they can modify the intensity of symptoms or affect the underlying disease process. The between-subject factor "drug" with two levels (with Betahistine dihydrochloride and without Betahistine dihydrochloride ) and three within subject factors: "time" with three levels (1 hour, 10 day, 20 day after treatment), "direction" (ML and AP) and "condition" (open and closed eyes). Ten day after pharmacological treatment the SV didn't change significantly than that in the first hour after EM.
The patients with duration of BPPV - PSC less than 60 days improved their postural stability, while posture of other patients (>60 days) was not influenced significantly by EM.
The results show dependence between efficacy of treatment with betahistine applied after EM and duration of BPPV. This particle cause a change of the endolymph flow in the semicircular canal and thus leads to abnormal excitability of vestibular receptors.
Vestibular suppressants and antiemetic drugs are still the basis of the acute treatment of vertigo, but are not effective for BPPV8-10.


In the eyes open condition the SV of both patient groups decreased significantly (P60 days) a difference between values of SV with and without pharmacological treatment no observed. The present study shows the beneficial effect of Betahistine dihydrochloride on the postural stability parameters when administered 20 days after physical treatment with Eplay maneuver. Betahistine normalized postural stability of patients with duration of BPPV less than 60 days after 10 days of treatment and had less effect on patients with duration of BPPV above 60 days.
Posterior semicircular canal is affected in approximately 85 to 95 percent of BPPV patients3.
Betahistine dihydrochloride is a histamine analogue which was introduced in the treatment of vertigo, motion sickness and various peripheral and central vestibular disorders of different origins11-13. Betahistine dihydrochloride normalized faster (at the 10th day of treatment) the postural stability of the patients with duration of BPPV less than 60 days and had less effect (statistically insignificant) on patients with duration of BPPV more than 60 days. We assume that after removing the otoconia betahistine plays an important role for improving blood flow in the inner ear.
Most of the patients complain of loss of equilibrium and unstable gait during and between the paroxysmal vertigo attacks. It has a very strong affinity for histamine H3 receptors and a weak affinity for histamine H1 receptors. The Epley maneuver removed otoconias in the affected semicircular canal and get them into a different part of the ear where they will be less likely to cause vestibular disturbance.
The short presence of otoconia didn't damage sensory receptor, and restoring the normal function of motion-sensitive hairs cells and stabilizing the posture was observed.
BPPV is diagnosed from patient history (feeling of vertigo with sudden changes in positions) and by performing the classic diagnostic maneuver of Dix-Hallpike and a clinical practice guideline criteria proposed by Bhattacharyya et al.2,4.
Betahistine seems to dilate the blood vessels within the inner ear, improve the microcirculation of the labyrinth, relieve pressure from endolymphatic fluid and act on the smooth muscle12-15. We suggest that after removing the otoconias the acute sensory conflict between the vestibular system and the vision probably diminished.
The test involves a reorientation of the head to align the posterior canal with the direction of gravity. Betahistine dihydrochloride is effective in reducing the number of vertigo attacks, their intensity score and their duration after 30-days treatment of BPPV with dosage of 16 mg twice a day16. This leads to disappearance of nystagmus, to restoration of the normal action of vestibulo-ocular reflex and to decrease of postural instability. During a movement in the vertical plane, the otoconia shifts and affects the motion-sensitive receptors situated in the semicircular canal.
In another study of patients with BPPV the application of a Betahistine dihydrochloride two weeks after a physical treatment showed better results for restoring vestibular function compared to the only physical treatment group17. We assume that the long presence of otoconias in the lumen or in the cupula of the semicircular canal permanently damaged the normal function of motion-sensitive hairs cells in the inner ear, because of that the therapy with EM and with Betahistine dihydrochloride 20 days after EM have a weak effect on the postural stability of patients with duration of BPPV above 60 days. Several reports have suggested that repositioning maneuver was effective for treatment the BPPV, but the symptoms relief and the postural stability was restored in different degree after physical treatment6,18,19,20. We suggest that a long lasting abnormality in the peripheral vestibular system activates some adaptation processes in central nervous system connected with mechanisms participating in the maintenance of posture and take a form of new pattern of postural stability in patients with duration of BPPV above 60 days, and the treatment with Betahistine dihydrochloride after EM is not effective. The principal therapy of BPPV is the removal of the otoconias by physical treatment with liberating maneuvers5,6 or Brandt-Daroff exercises7. Patients with BPPV showed impaired equilibrium and significantly higher postural sway parameters as sway velocity and amplitude, than healthy subjects when the visual and proprioceptive inputs were changed21,22.
For the other group of patients (less than 60 day duration of BPPV) the treatment with Betahistine dihydrochloride after EM is effective and ten days after treatment postural stability of patients was normalized.
That is a noninvasive procedure for repositioning of the head, clearing of the crystals out of the canal and depositing them back into the part of the inner ear where they belong. After the repositioning Epley maneuver the positioning vertigo and the typical nystagmus of patients with BPPV of the posterior semicircular canal (BPPV-PSC) disappeared, but the postural instability remained18,23-25. We assume that Betahistine dihydrochloride accelerates the recovery of function of vestibular system, by improving blood flow in the inner ear and normalization of the function of motion-sensitive hair cells is faster. Our earlier results showed that the postural maintenance in BPPV-PSC patients depended on the disease duration. One week after the Epley maneuver patients with duration of BPPV symptoms less than 60 days after the first attack do better in postural stability than those patients with more than 60 days duration of BPPV however without reaching normal values25.



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