Successful Treatment of Chronic Vertigo with Pomegranate Concentrated Juice: A Report of Two Cases

AUTHORS

Maryam Monfared 1 , 2 , Alireza Karimi-Yazdi 3 , * , Fataneh Dabaghian 1 , 2 , Farshad Amini Behbahani 1 , 2 , **

1 Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran

2 School of Iranian Traditional Medicine, Iran University of Medical Sciences, Tehran, Iran

3 Otorhinolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran

Corresponding Authors:

How to Cite: Monfared M , Karimi-Yazdi A, Dabaghian F, Amini Behbahani F. Successful Treatment of Chronic Vertigo with Pomegranate Concentrated Juice: A Report of Two Cases, Iran Red Crescent Med J. Online ahead of Print ; 21(2):e83103. doi: 10.5812/ircmj.83103.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 21 (2); e83103
Published Online: February 19, 2019
Article Type: Case Report
Received: August 9, 2018
Revised: May 11, 2018
Accepted: January 30, 2019
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Abstract

Introduction: Chronic vertigo is a disabling disease that influences the quality of life. There are simple and low-cost treatments in Iranian traditional medicine (ITM) with minimal side effects for some subtypes of this disease based on the ancient classification. One of them is gastric-related vertigo (GRV) that is diagnosed by a rational relationship between digestive symptoms and vertigo.

Case Presentation: Two adult patients with chronic vertigo were visited in the Behesht - Iranian traditional- medicine outpatient clinic of Iran University of Medical Sciences in Tehran, Iran, in the year 2017. They were evaluated and treated according to gastric-related vertigo management. The patients received 5 mL of pomegranate concentrated juice after each meal for four weeks. Their symptoms were checked after four weeks and the validated Persian version of dizziness handicap inventory (DHI) was completed for them as a pre-treatment and post-treatment monitoring tool.

Conclusions: Pomegranate concentrated juice as a stomach tonic led to the improvement of the digestive symptoms and vertigo. The six-month follow-ups after treatment were normal.

Keywords

Complementary Gastric Iranian Traditional Medicine Pomegranate Punicagranatum Vertigo

Copyright © 2019, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Introduction

Vertigo is a medical condition defined as the illusion of rotation, spinning, or swaying in the objects around or in the patient himself (1). Over the past decade, vertigo has been the most common complaint in the general population requiring specialist care and its prevalence increases with age (2, 3). A 7.4% lifetime prevalence of vertigo was observed among adults aged 18 to 79 years; also, its prevalence and annual incidences were 4.9% and 1.4%, respectively (4). Vertigo is usually classified into peripheral and central forms, based on the location of the dysfunction in the vestibular pathway (1). Peripheral vertigo is more common and occurs primarily due to inflammation, infection, and stimulation of various auditory organs or nerves. It is characterized by an episodic attack of vertigo along with precipitating factors; moreover, some autonomic symptoms like sweating, pallor, nausea, or vomiting may exist. Peripheral vertigo may also be associated with tinnitus, hearing loss, and auditory fullness. Central vertigo is often related to migraines, cerebrovascular disease, or cerebellopontine angle (CPA) tumors. In this disease, the autonomic symptoms are not severe, and hearing loss is uncommon. Central vertigo begins gradually and is associated with neurological symptoms such as visual changes (diplopia), weakness, numbness, dysarthria, ataxia, and loss of consciousness (1, 5).

Some of the patients have no complete treatment and long-term treatments have side effects and high costs; therefore, the use of complementary and alternative treatments has been emphasized.

In the current literature, there is some evidence of the efficacy of complementary remedies in the treatment of dizziness and vertigo.

Ginkgo biloba is as effective as betahistine in vertigo management (6). A clinical trial in an elderly population showed that the homeopathic preparation and Ginkgo biloba have similar effects in the treatment of vertigo (7). Moreover, medicinal herbs like Zingiber officinale (ginger) root could reduce the effects of vertigo better than did manual repositioning, such as the Epley maneuver alone (8). Furthermore, Gongjindan is completely effective in the treatment of subjects with chronic dizziness and vertigo (9).

There was a significant improvement in vertigo in a woman with chronic vertigo when the patient received four-month traditional Chinese medicine (TCM) treatment (10).

Another study suggested that the use of radical scavengers, i.e., rebamipide, vitamin C, and glutathione, could become a new effective treatment for Ménière’s disease (11).

Iranian traditional medicine (ITM) scholars were familiar with vertigo. They explained the etiology, clinical manifestations, and treatments of vertigo under the topic of “Dowar and Sadar” in their manuscripts. “Dowar” is defined as a disease with rotation sensation or spinning objects around the head and the body; as a result, sitting or standing becomes difficult for the patient (12-15). ”Sadar” is described as feeling lightheaded or dizzy after standing up. However, this term is not exactly the same as dizziness or vertigo and it is similar to orthostatic hypotension.

According to the ITM textbooks, there are some simple remedies to be used in the treatment of vertigo. These remedies are simple and low-cost with minimal side effects; some of them are classified as food, with definite therapeutic effects in different diseases in addition to their nutritional value. This study reports the results of complementary approaches for the diagnosis and treatment of vertigo based on ITM concepts.

2. Case Presentation

Two adult patients with chronic vertigo visited the Behesht ITM outpatient clinic of Iran University of Medical Sciences. The demographic characteristics of the patients are displayed in Table 1.

Table 1. Demographic Characteristics, Clinical and Para-Clinic Exams of the Patients
CharacteristicsPatient 1Patient 2
GenderFemaleMale
Age, y3647
JobProfessorEmployee
EducationHighLow
ParityYesYes
City of residenceTehranBirjand
Date of the first visit11 Sep. 201720 Nov. 2017
Frequency of attackEvery dayEvery two weeks
History of head traumaNegativeNegative
History of otolaryngeal surgeryNegativeNegative
Previous treatmentNegativeNegative
Abnormal physical examinationMild gastric and periumbilical tendernessMild periumbilical tenderness
Abnormal neurologic examination-Hearing loss in the left ear
Abnormal lab testsHemoglobin = 11 gm/dL, LDL = 128 mg/dL-
Brain MRINot performedNormal
Audiometric testNot performedSensory neural hearing loss in the left ear

2.1. Patient 1

A 36-year-old woman with a history of vertigo came to Behesht traditional medicine clinic on 11 Sep 2017. She was living in Tehran and suffered true vertigo twice a day that lasted at least three hours for three months. She had sometimes tinnitus and no hearing loss. She felt heaviness and hotness in the head and a headache every day after each meal. Her vertigo tended to get worse when she was hungry and soon after the meal. If she ate some types of food like garlic, onion, raisins, grapes, date, sweets, greasy foods, and pepper, her vertigo would have got worse. She had gastric reflux, flatus, and feeling of gastric heaviness. Sometimes, she had heartburns during vertigo. No medicine had been prescribed when she came to the complementary medicine clinic.

2.2. Diagnostic Tests

2.2.1. Lab Tests

Electrolyte levels, vitamin D level, thyroid function tests, BUN, creatinine, and uric acid were normal. WBC was normal but hemoglobin was 11 gm/dL and LDL was 128 mg/dL. The lab tests were repeated after treatment and six months later, and the results were almost the same.

2.2.2. Imaging

Brain MRI was recommended for her, but the patient ignored this advice because she tended to be treated with traditional medicine.

2.3. Patient 2

A 47-year-old man from Birjand (a city in eastern Iran) with a history of vertigo visited the Behesht traditional medicine clinic on 27 Nov 2017. He had true vertigo almost every two weeks with a duration of two hours for four years. When he was visited in the complementary medicine clinic, he felt heaviness, fullness, and hotness in his head. His vertigo got worse right after the consumption of greasy meal or spicy foods and it reoccurred after five hours. He had flatus, burps and sometimes, gastric heaviness after each meal and nausea while he had vertigo.

He visited a neurologist four years ago and brain MRI was normal; his audiometry showed a sensory neural hearing loss in the left ear and he took Betaserc (betahistine dihydrochloride) 8 mg daily for one year as prescribed by the neurologist; but if he was not taking the medicine, his vertigo would come back.

Each patient took 5 mL of pomegranate-concentrated juice after each meal for four weeks. Gastric heaviness, burps, flatus, and vertigo disappeared after four weeks.

The Dizziness Handicap Inventory (DHI) score as a pre-treatment and post-treatment measurement tool was used for both patients.

DHI has been developed to evaluate emotional, functional, and physical impairments due to dizziness (16). This scale is a patient-rated outcome that is widely used for patients with dizziness. The scale consists of 25 items (0 - 100 scores with 0, 2, or 4 scores/item). It has been validated in Iran (17).

Their symptoms were evaluated after the treatment and the results as pre-treatment and post-treatment scores are displayed in Table 2.

Their gastric symptoms got better, their vertigo’s attacks disappeared, and a six-month follow-up was normal.

Table 2. Pre-Treatment and Post-Treatment DHI Scores
No. of PatientScore
Patient 1
Pre-treatment48
Post-treatment12
Patient 2
Pre-treatment72
Post-treatment6

3. Discussion

Two general types of vertigo have been explained and classified in ITM:

1- Vertigo due to external causes: various cases of vertigo are caused by external factors (factors that are outside the human body) such as looking at a spinning object or turning around, sudden exposure to extreme cold or heat, head trauma, poisons, and drugs (12-15).

2- Vertigo with internal causes: in this type, vertigo results from diseases of body organs, and it is divided into two subtypes based on the origin of attack: (A) vertigo originating from intracranial causes for which the brain, clinical manifestations, and treatment methods have been mentioned in detail and (B) vertigo in relationship with the diseases of other body organs, which is named participatory vertigo. In this condition, some dysfunctions in an organ far from the brain like the stomach, the uterus, the bladder, the kidney, and the liver can influence the brain, which may be responsible for vertigo (12). The most important organ that participates in vertigo is the stomach (12, 14).

Gastric-related vertigo (GRV) is defined as vertigo that originates from the stomach. The etiology and symptoms of this type of vertigo have been discussed in detail and some medical herbs have been proposed for its treatment. There are some criteria for the diagnosis of GRV based on ITM references, including:

• The presence of vertigo or the increase of its severity along with symptoms of dyspepsia (digestions weakness) like the feeling of gastric heaviness or reflux, sour eructation, preference of spicy food, drooling of the saliva or suffer from

• The presence of vertigo or the increase of its severity by hunger and relief after eating food along with other gastric symptoms like the feeling of bitterness and dryness in the mouth, excessive thirst, and being satisfied with it with cold water, or bad-smell burp.

• The presence of vertigo along with symptoms of stomachache, periumbilical pain, flatus, or gastric reflux.

• Nausea and vomiting before vertigo and relief of vertigo after vomiting.

• The presence of vertigo or the increase of its severity after eating some food likes garlic, pepper, onion, cabbage, melon, and date along with other gastric symptoms likes flatus, burps, nausea, and mouth bitterness (12-15).

In ITM, the treatment of the stomach is the first step of disease management in these patients. The treatment is completed by the prescription of cerebrotonic foods and herbs to prevent recurrence and relapse (12). In this study, we used pomegranate-concentrated juice for improving gastric symptoms in two patients. Several studies suggest that pomegranate has some effects on the gastrointestinal tract. Pomegranate (Punicagranatum L.) is a remedy considered as a gastric tonic agent by ITM. It has a tonic effect on the cardia and stomach, and improves digestion and reflux (12-15).

Pomegranate has many phytochemical compounds such as polyphenols and flavonoids, tannins, and anthocyanin (18). The phenolic compounds of pomegranate have prophylactic and therapeutic utilities against various pathological infections, as well as non-infectious disorders (19). Pomegranate polyphenols, especially ellagitannins and ellagic acid, have antioxidant and anti-inflammatory properties (20) and have therapeutic effects on inflammatory bowel disease (21-23). Pomegranate tannins play a protective role against gastric ulcer (24, 25). Pomegranate has effectiveness in reducing nausea and vomiting during pregnancy (26). It has anti- H. pylori and anti-inflammatory effects in the gastrointestinal tract (27, 28). Moreover, it shows antibacterial activity against intestinal flora (28, 29). It also has an inhibitory effect on gastric mucosal injury (30).

In our patients, GRV was suggested as a differential diagnose because vertigo occurred or got worse when they were hungry, soon after each meal, and when eating some types of food. They had some gastric symptoms like flatus, burps, and gastric heaviness.

Therefore, they were treated with pomegranate concentrated juice. The avoidance of garlic, pepper, raw onion, cabbage, melon, date, and greasy food was recommended for four weeks. Their gastric symptoms got better, their vertigo’s attacks disappeared, and a six-month follow-up was normal.

We did not find any evidence of the direct effect of pomegranate on the vestibular system of the ears but its effect on gastric diseases has been proved. Reducing gastroesophageal reflux and preventing the effect of pepsin on the middle ear may be considered an explanation (31).

3.1. Suggestion

Future studies can focus on the more accurate evaluation of the efficiency of pomegranate on vertigo, creating simple questionnaires for the diagnosis of GRV, evaluation of other recommended gastric tonics in ITM on vertigo, and evaluation of the possible effects of these tonic foods and ingredients on the vestibular system.

Acknowledgements

Footnotes

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