BACKGROUND AND PURPOSE: Although acute attacks of benign paroxysmal positional vertigo (BPPV) may be treated with canalith repositioning maneuvers, there have been no well-designed prospective trials to prevent this highly prevalent and recurrent disorder. This topical review explores the evidence related to the association between deficient calcium metabolism and BPPV. We also describe the development of therapeutic options to prevent recurrences of BPPV and introduce results from a recent randomized controlled trial on the effect of vitamin D and calcium supplementation in preventing BPPV recurrences. SUMMARY OF KEY POINTS: The literature describes 3 lines of evidence on association of impaired calcium metabolism and development of BPPV: (1) decreased bone mineral density was more frequently observed in persons with BPPV than in healthy controls; (2) estrogen plays a vital role in maintenance of otoconia, and estrogen deficiency appears to precipitate degeneration of otoconia and development of BPPV; and (3) lower serum vitamin D level is associated with development of BPPV, and supplementation of vitamin D and calcium carbonate may reduce further attacks of BPPV in persons with BPPV and subnormal serum vitamin D level. RECOMMENDATIONS FOR CLINICAL PRACTICE: Restoration of impaired calcium metabolism with supplementation of vitamin D or estrogen should be considered in the treatment of individuals with frequent recurrences of BPPV. Future randomized controlled trials are mandatory to validate these supplementation therapies in individuals with recurrent BPPV.