The Herbalist’s Corner
Jake Paul Fratkin, OMD, L.Ac.
In vertigo, the patient experiences spinning, loss of balance, and occasionally nausea. It can manifest in a sitting or sleeping posture, or only show once the patient stands up or walks around. The clinician should distinguish acute situations versus chronic. In acute situations, chiropractic adjustment is the first therapy to consider, and can often relieve the situation immediately. In cases with a history of acute episodes, one should also consider the Eply maneuver. This treats cases of vertigo that are due to sand in the inner ear, and the maneuver tests for, and releases by gravity, this sand. It can be quite effective, and patients can learn to do it themselves. Acupuncture can also be effective, although success with acupuncture alone eludes many practitioners. Effective results can be obtained when using Chinese herbal formulas, however.
Vertigo and dizziness affect 20-30% of the general population, with the majority being older women. Modern medicine distinguishes three types of vertigo. In objective vertigo, the patient has the sensation that the environment is moving. In subjective vertigo, the patient feels as if he or she is moving, and in pseudo-vertigo, there is a sensation of rotation inside the patient’s head. Medical diagnoses include benign paroxysmal positional vertigo (BPPV), Ménière’s disease and vestibular neuritis. It may also be due to trauma, fever, migraine, and excessive alcohol consumption.
In Traditional Chinese Medicine, vertigo and dizziness are due to symptom-complexes of root deficiency and branch excess. There are a variety of etiological factors that can cause the condition. Emotional depression or anger can damage liver yin and result in the rise of liver yang or wind. Extended illness, stress, anxiety, over-pensiveness, or weak heart and spleen can cause deficiency of qi and blood. Overindulgent sexual activity, extended illness, or advancing years can lead to deficiency of kidney jing. Improper diet and eating habits, stress and overwork, can damage the spleen and stomach, allowing obstruction of the middle jiao by phlegm-dampness or phlegm-fire. The pathogenesis of vertigo and dizziness is complex, and basically all cases will involve wind, fire, phlegm, or deficiency.
In clinical practice, vertigo and dizziness are distinguished by degree, with vertigo as a more serious manifestation. In vertigo, the head feels as if wrapped in a wet towel, with symptoms of spinning and loss of balance. The etiological cause is an underlying deficiency of spleen qi with accumulation on heat in the middle jiao. This leads to food stagnation and phlegm, and if truth were told, phlegm is the key pathogenic factor in vertigo. Underlying deficiencies of kidney yin and jing can generate liver wind, driving phlegm upwards. In TCM, this can be referred to simply as endogenous wind-phlegm. Effective herbal formulas should address this complex of deficiency, wind, heat and phlegm.
There are various classical formulas used for vertigo and dizziness, including Chai Hu Jia Long Gu Mu Li Tang, Tian Ma Gou Teng Yin, Zhen Gan Xi Feng Tang and Ban Xia Bai Zhu Tian Ma Tang. The first two formulas address liver wind, but do not adequately dissolve phlegm. Clinically, I do not think they are effective for vertigo, although they can be useful for deficiency dizziness.
I find that the most effective formula for vertigo is Ban Xia Bai Zhu Tian Ma Tang (“Pinellia, Atractylodes, Gastrodia Decoction”). There are actually two different versions of this formula, appearing at two different historic periods and with two different sets of ingredients. In modern times, some manufacturers follow one formula while others follow the other formula. Most practitioners don’t know this, and I want to use this opportunity to point out who is offering what.
The original Ban Xia Bai Zhu Tian Ma Tang was authored by Li Dong-Yuan in 1249. It is available from the extract granule manufacturers using the standardized Taiwan prescription (Sunten, Qualiherb, Mintong, KPC, Guang Ci Tong, as well as Nuherbs, Evergreen, etc), under the name Pinellia & Gastrodia Combination or Ban Xia Bai Zhu Tian Ma Tang. The formula is:
ban xia (Rhizoma Pinelliae) 16.8 %
mai ya (Fructus Hordei Germinatus) 16.8
bai zhu (Rhizoma Atractylodis Macrocephalae) 10.8
shen qu (Massa Medicata Fermentata) 10.8
tian ma (Rhizoma Gastrodiae) 5.6
ren shen (Radix Ginseng) 5.6
cang zhu (Rhizoma Atractylodis) 5.6
huang qi (Radix Astragali) 5.6
ze xie (Rhizoma Alismatis) 5.6
chen pi (Pericarpium Citri Reticulatae) 5.6
fu ling (Poria) 5.6
gan jiang (Rhizoma Zingiberis) 3.4
huang bai (Cortex Phellodendri Chinensis) 2.2
Here, 61% of the formula clears phlegm and dampness (ban xia, mai ya, shen qu, fu ling, cang zhu and ze xi), with Pinellia ban xia being the key herb to dissolve phlegm. Shen qu and Hordeum mai ya breaks up food stagnation, the source of the phlegm that eventually wraps the head. These two herbs make up 27% of the formula. A further 22% tonifies spleen qi (bai zhu, ren shen, and huang qi). Gastrodia tian ma is the main herb to extinguish and settle liver wind, and a small amount of Phellodendron huang bai clears heat. This formula is valuable because of the large amount of herbs that clear phlegm, which is the main pathogenic factor is vertigo.
The second version of Ban Xia Bai Zhu Tian Ma Tang was created by Cheng Guo-Peng in 1732. It is available in its Chinese name by Plum Flower, Blue Poppy, and Tanglong. Kan offers it as Ascending Clarity, and Chinese Classics has it as Pinellia, Atractylodes & Gastrodia. This is a smaller formula (8 herbs versus 13), with the following ingredients (percentages from the Tanglong version):
fu ling (Poria) 21.0 %
ban xia (Rhizoma Pinelliae) 15.8
bai zhu (Rhizoma Atractylodis Macrocephalae) 15.8
da zao (Fructus Jujubae) 15.8
tian ma (Rhizoma Gastrodiae) 10.5
ju hong (Exocarpium Citri Rubrum) 10.5
gan cao (Radix Glycyrrhizae) 5.3
sheng jiang (Rhizoma Zingiberis Recens) 5.3
It contains four herbs from the original formula (fu ling, ban xia, bai zhu and tian ma), and adds in da zao, gan cao, ju hong and sheng jiang. Here, 37% of the formula addresses phlegm and dampness, and 37% addresses spleen qi deficiency. It has a stronger amount of Gastrodia tian ma (10.5%).
Both formulas are effective for vertigo due to wind phlegm. Given the ingredients, I would prefer the first formula, which is more aggressive for dissolving phlegm.
Other practical approaches for vertigo would be to combine Er Chen Tang, Ban Xia Hou Po Tang, or Wen Dan Tang with one of the other liver wind formulas mentioned above: Cha Hu Jia Long Gu Mu Li Tang, Tian Ma Gou Teng Yin, or Zhen Gan Xi Feng Tang. The formulas Er Chen Tang, Ban Xia Hou Po Tang and Wen Dan Tang contain herbs necessary for dissolving phlegm that is the core of heavy-headed vertigo. The ingredients for these formulas are as follows:
Er Chen Tang. Ingredient percentages from Herbal Times’ “Er Chen Wan”.
chen pi ( Pericarpium Citri Reticulatae) 32.3 %
ban xia (Rhizoma Pinelliae) 32.2
fu ling (Poria) 19.5
gan cao (Radix Glycyrrhizae) 10.0
sheng jiang (Rhizoma Zingiberis Recens) 6.0
Ban Xia Hou Po Tang. Ingredient percentages from the standardized “Pinellia & Magnolia Combination”.
ban xia (Rhizoma Pinelliae) 30.0 %
sheng jiang (Rhizoma Zingiberis Recens) 25.0
fu ling (Poria) 20.0 hou po (Cortex Magnoliae Officinalis) 15.0
zi su ye (Folium Perillae) 10.0
Wen Dan Tang. Ingredient percentages from the standardized “Hoelen/Poria & Bamboo Combination”.
chen pi (Pericarpium Citri Reticulatae) 24.0 %
ban xia (Rhizoma Pinelliae) 15.9
zhi shi (Fructus Aurantii Immaturus) 15.9
zhu ru (Caulis Bambusae in Taenia) 15.9
fu ling (Poria) 11.1
gan cao (Radix Glycyrrhizae) 6.2
sheng jiang (Rhizoma Zingiberis Recens) 6.2
da zao (Fructus Jujubae) 4.8
The treatment of vertigo can be challenging to the clinician, and certainly the condition of vertigo is debilitating to the patient. In cases due to wind-phlegm, prolonged herbal treatment may be necessary.