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Dizziness/Vertigo

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Related Terms
  • Acoustic nerve, agoraphobia, aminoglycoside, anxiety, arrhythmia, audiometry, benign paroxysmal positional vertigo, BPPV, bradycardia, brainstem, cardiomyopathy, cardiovascular disease, CBC, central vestibular disorders, cerebellum, Cogan's syndrome, complete blood count, diplopia, dysarthria, electronystagmography, endolymph, endolymphatic sac procedure, ENG, hemorrhage, hyperventilation, labyrinth, labyrinthectomy, labyrinthitis, magnetic resonance imaging, Meniere's disease, migraine, MRI, myringotomy, objective vertigo, orthostatic hypotension, otitis media, ototoxicity, peripheral vestibular disorders, presyncope, stroke, subjective vertigo, tachycardia, thyroid disorders, tinnitus, vertigo, vestibular nerve, vestibular neurectomy, vestibular neuritis, vestibular rehabilitation therapy, vestibular system, VRT.

Background
  • Dizziness is a symptom, not a disease. Dizziness is defined as a feeling of being woozy, drunk, unsteady, or giddy. It is a general term used to describe the sensation of imbalance.
  • Individuals often describe balance problems in terms of vertigo, dizziness, lightheadedness, and motion sickness.
  • The term vertigo refers to a specific type of dizziness that causes the sensation of spinning or whirling. This generally occurs as a result of a disturbance in balance (equilibrium). Vertigo also may be used to describe feelings of dizziness, lightheadedness, faintness, and unsteadiness. For the purposes of this monograph, vertigo and dizziness will be used interchangeably.
  • Vertigo is one of the most common health problems in adults. According to the National Institutes of Health (NIH), about 40% of people in the United States experience feeling dizzy at least once during their lifetime. Prevalence is slightly higher in women and increases with age.
  • While the majority of individuals with dizziness experience mild to moderate symptoms, severe symptoms of dizziness involving disability are seen in an estimated 10% of the patients.
  • Vertigo may be related to disorders of the vestibular system (the system of balance), injury, or medications. As individuals age, they also become more prone to vestibular disorders, such as vertigo.

Signs and symptoms
  • Vertigo refers to the sensation of spinning or the perception that surrounding objects are moving or spinning. Some individuals describe a feeling of being pulled toward the floor or toward one side of the room. Moving the head, changing position, and turning while lying down often worsen vertigo.
  • The sudden onset of vertigo usually indicates a peripheral vestibular disorder (such as benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuritis).
  • Symptoms of benign paroxysmal positional vertigo (BPPV) usually last a few seconds to a few minutes and come and go. They also may include lightheadedness, imbalance, and nausea, usually as a result of a change in position (such as when rolling over in bed or getting out of bed). Symptoms of Meniere's disease and vestibular neuritis include vertigo, hearing loss, ringing in the ears (tinnitus), and ear pressure that often last hours to days.
  • Peripheral vestibular disorders also may cause the following symptoms: blurred vision; fatigue and reduced stamina; headache; heart palpitations or arrhythmias (rapid fluttering of the heart); imbalance; inability to concentrate; increased risk for motion sickness; muscle ache (especially of the neck and back); nausea and vomiting; reduced cognitive function (including thinking and memory); sensitivity to bright lights and noise; and increased sweating.
  • Vertigo caused by a central vestibular disorder usually develops gradually. Central vestibular disorders are usually caused by underlying health conditions, such as stroke or migraine. These central vestibular disorders may cause symptoms including: double vision (diplopia); headache (may be severe); impaired consciousness; inability to speak due to muscle impairment (dysarthria); lack of coordination; nausea and vomiting; and weakness.

Diagnosis
  • It is important for a doctor to diagnose the cause of vertigo (dizziness) as quickly as possible to rule out serious conditions such as cardiovascular disease, stroke, hemorrhage, or tumor.
  • In trying to determine the cause of vertigo, a doctor may ask if the dizziness: causes the room to spin or produces a sensation of motion; is associated with a feeling of faintness or lightheadedness; or causes the individual to lose balance.
  • Physical examination includes measuring blood pressure and heart rate. Neurological examination includes testing facial and vestibular nerves and muscles, strength, coordination, balance, and walking (gait).
  • The positional vertigo test is used to help distinguish peripheral from central vestibular disorders. In this test, the individual sits on a table with the head turned to the side. The doctor then supports the head and lowers it gently below the table while the individual lies back. The individual reports symptoms of vertigo while the doctor looks for circular movement of the eyes (called nystagmus). A delay between the onset of nystagmus and the sensation of vertigo usually indicates a peripheral vestibular disorder. Lack of a delay may indicate a central vestibular disorder. The test is repeated with the head turned in the opposite direction.
  • Electronystagmography (ENG): Electronystagmography (ENG) is a neurological test used to evaluate the vestibular system. ENG involves testing hearing in both ears (audiometry tests), testing eye movements, and evaluating responses to changes in posture and position. In a darkened room, recording electrodes are placed near the eyes. Warm and cool water or air is gently introduced into each ear canal. Since the eyes and ears work in coordination through the nervous system, measurement of eye movements can be used to test the balance system. In about 50% of individuals, the balance function is reduced in the affected ear. Rotational testing or balance platform may also be performed to evaluate the balance system.
  • Blood tests: Blood tests include a complete blood count (CBC) and kidney and thyroid panels to rule out systemic diseases (such as kidney disease or thyroid disorders). If the individual is taking medications (such as aminoglycosides or anticonvulsants), drug levels are obtained.
  • Imaging tests: Imaging tests may be used to detect brain abnormalities (such as stroke or tumor). A magnetic resonance imaging (MRI) test uses a magnetic field and radio waves to create cross-sectional images of the head and body. A doctor can use these detailed, clear images to identify and diagnose a wide range of conditions that may cause vertigo.

Complications
  • Severe vertigo can be disabling and may result in complications such as irritability, loss of self-esteem, depression, negative effects on work performance and quality of life, and injuries from falls. Falls are the leading cause of serious injury in people over the age of 65.
  • Experiencing dizziness while driving a car or operating heavy machinery can increase the likelihood of an accident.
  • Dizziness may also lead to nausea and vomiting.

Treatment
  • Treatment for vertigo, or dizziness, depends on identifying and eliminating the underlying cause. If a particular medication is responsible for the condition, lowering the dosage or discontinuing the drug may eliminate vertigo.
  • Endolymphatic sac procedures: Endolymphatic sac procedures are surgical procedures that reduce the swelling caused by endolymph (an inner ear fluid) buildup. In endolymphatic sac decompression, some of the bone surrounding the inner ear is removed. In some cases, endolymphatic sac decompression is coupled with the placement of an endolymphatic shunt, a tube that drains excess fluid from the inner ear. Another surgical approach called a sacculotomy involves implanting a permanent, tack-like device that allows endolymph to drain out of the inner ear whenever pressure builds up.
  • If vertigo appears without warning, the individual should not drive. Failure to control the vehicle may be hazardous to the individual and others. It is also best to avoid activities that require balance such as climbing ladders, scaffolds, and swimming (due to the possibility of drowning).
  • Labyrinthectomy: A labyrinthectomy removes the entire inner ear sense organ (vestibular labyrinth). The operation may be an option if antibiotic injections do not help and the individual has near-total or total hearing loss in the affected ear.
  • Lifestyle changes: Healthcare professionals recommend that individuals with conditions causing vertigo to: avoid caffeine, smoking, and alcohol; get regular sleep; eat a healthy diet, including fresh fruits and vegetables and limiting meats and fatty foods; and avoid foods that contain MSG or monosodium glutamate. Prepackaged food products and Chinese foods include MSG, which contains sodium. MSG can contribute to fluid retention and worsen symptoms. Stress may aggravate vertigo. Stress avoidance or counseling may be advised.
  • Medications: A low salt diet and a prescription diuretic, or water pill (such as hydrochlorothiazide), may reduce the frequency of attacks of dizziness in some individuals. Because diuretic medications cause the individual to urinate more frequently, their body may become depleted of certain minerals, such as potassium. Healthcare providers may recommend taking a potassium supplement or eating three or four extra servings of potassium-rich foods a week, such as bananas.
  • A middle ear injection consists of a healthcare professional injecting gentamicin (Garamycin®, a toxic antibiotic) in the inner ear, through the eardrum and into the inner ear. The gentamycin can now be absorbed. This reduces the balancing function of the individual's ear, and their other ear assumes responsibility for balance. The procedure, which can be performed with local anesthesia in a doctor's office, often reduces the frequency and severity of vertigo attacks.
  • Middle ear injections with a steroid, such as dexamethasone (Decadron®), may also help control vertigo attacks in some individuals. Although dexamethasone injections may be slightly less effective than gentamicin, dexamethasone is less likely than gentamicin to cause further hearing loss.
  • Anti-vertigo medications, such as meclizine (Antivert®), may provide temporary relief from vertigo. Anti-nausea medication is sometimes prescribed, such as prochlorperazine (Compazine®). Anti-anxiety drugs, such as alprazolam (Xanax®), may also be used if the individual has vertigo due to anxiety. Anti-vertigo, anti-nausea, and anti-anxiety medications may cause drowsiness. Alprazolam is in a class of drugs called benzodiazepines. These medications may cause physical and psychological addiction.
  • Anticholinergic medications may also be used to decrease dizziness. These drugs include scopolamine patches (Transderm Scop®).
  • Surgery: If the vertigo attacks are severe and debilitating and medical treatments do not help, surgery may be an option. A myringotomy is a surgical procedure that may be used to treat chronic ear infections. In this procedure, which is performed under anesthesia, an incision is made in the eardrum and a small tube is placed in the opening to prevent fluid and bacteria from building up inside the ear.
  • Vestibular neurectomy: A vestibular neurectomy involves cutting the nerve that controls balance (vestibular nerve). When intense vertigo is experienced, a vestibular neurectomy may be done to surgically destroy the entire inner ear. The individual's other ear then takes over the balance function.
  • Vestibular rehabilitation therapy: Vestibular rehabilitation therapy (VRT) is a type of physical therapy used to treat vertigo. The goal of treatment is to minimize dizziness, improve balance, and prevent falls by restoring normal function of the vestibular system. In VRT, the individual performs exercises designed to allow the brain to adapt to and compensate for whatever is causing the vertigo. The success of this treatment depends on several factors including the following: age of the patient (the younger the individual, the more responsive to treatment); cognitive function (such as memory and the ability to follow directions in order); coordination and motor skills; overall health of the individual (including the central nervous system); and physical strength.

Integrative therapies
  • Unclear or conflicting scientific evidence:
  • Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Today, it is widely used throughout the world and is one of the main pillars of Chinese medicine. Early evidence suggests that deep needling may be more effective in treating sudden deafness than shallow needling. Better-designed trials are needed to reach a firm conclusion. Both jinger moxibustion and acupuncture have been studied for cervical vertigo, although few conclusions can be made at this time.
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. Limited research suggests that functional reach performance may be improved through Alexander technique instruction, particularly in people older than 65 years. Better quality evidence is needed before a conclusion can be made.
  • Serious side effects of the Alexander technique have not been reported. It has been suggested that the technique may be less effective with learning disabilities or mental illnesses. The Alexander technique has been used safely in pregnant women.
  • Chiropractic: Chiropractic therapy is a type of healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system). It focuses on how this relationship affects the preservation and restoration of health. The broad term "spinal manipulative therapy" incorporates all types of manual techniques, including chiropractic. There is currently insufficient evidence to recommend chiropractic manipulative therapy for the treatment of cervical vertigo.
  • Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders or migraines. Use cautiously with a risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.
  • Feldenkrais method®: It has been suggested that the Feldenkrais Method® may help improve balance problems or function, but there is little available research. There is currently a lack of available scientific studies or reports of safety of the Feldenkrais Method®.
  • Ginkgo: Ginkgo, or Ginkgo biloba, has been used medicinally for thousands of years. Today, it is one of the top selling herbs in the United States. Preliminary study has been conducted on the effects of ginkgo in chronic cochleovestibular disorders and vertigo. Additional study is needed before a conclusion can be made.
  • Ginkgo may cause bleeding in sensitive individuals, such as those with bleeding disorders or those taking medications such as aspirin or warfarin (Coumadin®). Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding.
  • Hellerwork: Hellerwork is a form of deep tissue bodywork and movement therapy that was developed in the 1970s by aerospace engineer Joseph Heller. It uses multiple techniques, including deep-tissue bodywork, movement education and verbal interaction to improve posture and movement patterns. High-quality scientific evidence on the effects of this technique for balance and posture is currently unavailable.
  • Hellerwork should not be used as the sole therapeutic approach to disease, and it should not delay the time to speak with a health care provider about a potentially severe condition. In theory, Hellerwork may make some existing symptoms worse. Deep-tissue massage is not advisable in some conditions. Speak with a qualified healthcare professional before starting treatment. Use cautiously with psychosis or bipolar disorder, bleeding disorders, bone or joint disorders using blood thinners (rheumatoid arthritis, ankylosing spondylitis or aortic aneurisms), history of blood clots, recent abdominal surgery, or major diseases of internal organs. Use cautiously in women who are menstruating and in people with severe diseases of the kidneys, liver or intestines. Avoid with recent musculoskeletal injury, trauma, or major surgery. Avoid with broken bones, severe osteoporosis, disease of the spine or vertebral disks, skin damage or wounds, bleeding disorders, or blood clots in areas being manipulated. Avoid if pregnant or breastfeeding.
  • Meditation: Meditation (in the form of Tai Chi or Qi gong) may help to improve balance in healthy elderly people. More research is needed.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
  • Physical therapy: Physical therapy has been used to treat vertigo (specifically, benign paroxysmal positional vertigo). Physical therapy protocols are not well outlined, and there is limited study comparing physical therapy to other modalities. Nevertheless, physical therapy may be helpful for vertigo, but more study is needed.
  • Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
  • Tai chi: Tai chi is a system of movements and positions believed to have been developed in 12th Century China. Early research suggests that tai chi practice may improve balance and strength maintenance. These benefits may be similar to other forms of exercise. Additional research is necessary before a conclusion can be reached.
  • Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

Prevention
  • Healthcare professionals recommend that if an individual is susceptible to vertigo (dizziness), they should: be aware of the possibility of losing balance, which can lead to falling and serious injury. Patients are directed to sit or lie down immediately when feeling dizzy; avoid driving a car or operating heavy machinery if experiencing frequent dizziness; use good lighting when getting out of bed at night; walk with a cane for stability; and avoid using caffeine, alcohol, and tobacco. Excessive use of these substances can constrict blood vessels and worsen signs and symptoms. Always work closely with a doctor to manage symptoms effectively. A doctor or pharmacist can also advise the individual about certain medications that may cause dizziness.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American Academy of Family Physicians. . Accessed March 22, 2009.
  2. American Academy of Otolaryngology - Head and Neck Surgery. . Accessed March 22, 2009.
  3. American Hearing and Research Foundation. . Accessed March 22, 2009.
  4. Barozzi S, Di Berardino F, Arisi E, et al. A comparison between oculomotor rehabilitation and vestibular electrical stimulation in unilateral peripheral vestibular deficit. Int Tinnitus J. 2006;12(1):45-9.
  5. Cakir BO, Ercan I, Cakir ZA, et al. Efficacy of postural restriction in treating benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. 2006;132(5):501-5.
  6. Middleton ET, Steel SA. The effects of short-term hormone replacement therapy on long-term bone mineral density. Climacteric. 2007;10(3):257-63.
  7. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed March 22, 2009.
  8. Pytel J, Nagy G, Toth A, et al. Efficacy and tolerability of a fixed low-dose combination of cinnarizine and dimenhydrinate in t he treatment of vertigo: a 4-week, randomized, double-blind, active- and placebo-controlled, parallel-group, outpatient study. Clin Ther. 2007;29(1):84-98.
  9. Venosa AR, Bittar RS. Vestibular rehabilitation exercises in acute vertigo. Laryngoscope. 2007;117(8):1482-7.

Causes and risk factors
  • Vertigo usually occurs as a result of a disorder in the vestibular system. The vestibular systems are structures of the inner ear, the vestibular nerve, brainstem, and cerebellum that deal with balance. The vestibular system is responsible for integrating sensory stimuli and movement and for keeping objects in visual focus as the body moves. Blurred vision may also lead to dizziness.
  • When the head moves, signals are transmitted to the labyrinth. The labyrinth is a structure in the inner ear that is made up of three semicircular canals surrounded by fluid. The labyrinth transmits movement information to the vestibular nerve, which then carries the information to the brainstem and cerebellum (areas of the brain that control balance, posture, and motor coordination). There are a number of different causes for dizzy spells.
  • Central vestibular disorders: Central vestibular disorders that may cause vertigo include cardiovascular disorders, such as bradycardia (heart rate below 90 beats per minute) or tachycardia (rapid heart rate exceeding 100 beats per minute), central nervous system (CNS) disorders including stroke (a lack of oxygen to the brain due to loss of blood flow, resulting in neurological damage), brain hemorrhage (bleeding), and head trauma; migraine (30-50% of migraine patients experience vertigo); joint and muscle conditions, including multiple sclerosis (MS), occurring when muscle loss affects the brainstem or cerebellum. Other causes of vertigo include orthostatic hypotension (a sharp decrease in blood pressure upon rising from a lying or sitting position to a standing position), which is caused by diabetes, dehydration, anemia, and some medications, hypotension in general, and diseases, such as kidney disease, thyroid disorders, and cancer. Tumors can also affect the central vestibular system (acoustic neuroma).
  • Rapid changes in motion, such as riding on roller coasters, in boats, cars, or even airplanes, may occasionally make individuals experience dizziness. This type of dizziness is called motion sickness.
  • Peripheral vestibular disorder: There are several types of peripheral vestibular disorders that can occur and cause vertigo (dizziness), including benign paroxysmal positional vertigo or BPPV. BPPV is the most common peripheral disorder and may be accompanied by hearing loss, reduced cognitive function, and facial muscle weakness. Another peripheral vestibular disorder causing vertigo is Cogan's syndrome, which is inflammation of connective tissue in the cornea. The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber, providing most of an eye's optical power. Cogan's syndrome results in vertigo, ringing in the ears (tinnitus), and loss of hearing. Also, Meniere's disease, which is fluctuating pressure of inner ear fluid (endolymph), results in severe vertigo, ringing in the ears (tinnitus), and progressive hearing loss. Ototoxicity, or the loss of hearing due to certain medications (including anticonvulsants and certain antibiotics), and vestibular neuritis, or inflammation of vestibular nerve cells, may also cause vertigo. Vestibular neuritis may be caused by a viral infection.
  • Medications: Some medications, such as certain diuretics (including furosemide or Lasix®), and aspirin, can cause ototoxicity or loss of hearing that may lead to dizziness. Ototoxicity may result in damage to the inner ear or the 8th cranial nerve (acoustic nerve) and cause vertigo. The damage can be permanent or temporary.
  • Long-term use or high doses of antibiotics such as aminoglycosides (including streptomycin, gentamicin, and tobramycin), macrolide antibiotics (such as erythromycin), vancomycin, and antineoplastics or chemotherapy drugs (such as cisplatin and carboplatin) can cause permanent ototoxicity.
  • Other medications that may cause temporary ototoxicity include: anticonvulsants, such as phenytoin (Dilantin®) and carbamazepine (Tegretol®); antidepressants, such as clomipramine (Anafranil®) and amoxapine (Asendin®); antihypertensives, such as labetolol (Trandate® or Normodyne®) and enalapril (Vasotec®); loop diuretics, such as bumetanide (Bumex®) and furosemide (Lasix®); pain relievers, such as aspirin; and quinine (chloroquine, quinidine). Alcohol, even in small amounts, can cause temporary vertigo in some people.
  • Centrally acting drugs, including pain mediactions such as morphine, and anti-anxiety drugs, such as diazepam (Valium®), may also cause dizziness.
  • Presyncope: Presyncope is the medical term for feeling faint and lightheaded without losing consciousness. Sometimes nausea, pale skin and a sense of dizziness accompany a feeling of faintness. Causes of presyncope include: a sudden drop in blood pressure (orthostatic hypotension. A dramatic drop in systolic blood pressure (the pressure due to the heart contracting or the higher number in a blood pressure reading) may result in lightheadedness or a feeling of faintness. Presyncope can occur after sitting up or standing too quickly due to orthostatic hypotension; and an inadequate output of blood from the heart (congestive heart failure). Conditions such as partially blocked arteries (atherosclerosis), disease of the heart muscle (cardiomyopathy), abnormal heart rhythm (arrhythmia), or a decrease in blood volume may cause inadequate blood flow from the heart.
  • Others: A lightheaded feeling can be caused by inner ear disorders, such as otitis media (inner ear infection) and anxiety disorders. Certain anxiety disorders, such as panic attacks and a fear of leaving home or being in large, open spaces (agoraphobia), may cause lightheadedness and hyperventilation. Abnormally rapid breathing that often accompanies psychiatric disorders, such as anxiety, may make an individual feel lightheaded.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.


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