Treating a vestibular disorder can feel impossible – but here’s the good news, it is not impossible to treat a vestibular disorder! I have to say this first: do not give up hope when trying to treat your vestibular disorder. Dizziness can lead to infinite doctors appointments, feelings of frustration, and thinking that you might throw in the towel.
Vestibular Disorder Treatment
Vestibular Disorder treatment does require hard work and multiple doctors who know what they’re talking about. If you haven’t found one yet, please check VEDA (or here if you’re in the UK). Treatment is multimodal, meaning that you need multiple healthcare providers to do their jobs together as a team to help you- this is not a single-doctor-only diagnosis. It’s essential that your whole team works together, talks you each other, and is aware of your plan and changes to that plan.
Top Three Tips for Dizziness Treatment
Track your triggers (in the short term)
Tracking your triggers means that you should write down what you eat, the weather, your sleep, and your symptoms daily. I recommend doing this for four weeks. For some, this becomes a stress-inducing habit, and if that is the case for you, please do not do this and enlist the help of a professional!
Find an Excellent Healthcare Team
Finding healthcare providers that treat vestibular disorders can be difficult, but finding a person to listen to you and help you differentiate the diagnoses is endlessly helpful. IF you can’t find a provider on the VEDA link above, find a neurotologist to help you in your area or via telehealth. Most of the exam when diagnosing dizziness is subjective. If you’ve been to multiple doctors and already had standard testing (MRI, CT, etc.), you may be able to go to an out-of-state doctor via telehealth. Another important team member is a vestibular physical therapist. PTs are the ones who are going to help you get your life – return to function is through PT!
Be Consistent about your Treatment
Consistency is key in any major life change, especially with chronic illnesses. There are no quick fixes. Finding things that work for you can be a long journey, but it is helpful in the long run. If you can consistently change a few things here and there, it is often more valuable than making one significant change. Again, treating vestibular disorders is a holistic journey. You will likely trial and error many treatment options before you find out what works for you. Keep track of what you have tried (write it down, I love to do this in an excellent journal), keep a record of your symptoms and your flare-ups, and also track what did not work. Medications, diets, and more have likely been thrown at you, and trying many routes isn’t a bad idea.
Finding your Beginning
Everyone begins at their beginning – we don’t have the same starting point as anyone else. It’s important to remember that even when we ask others who have been where we are now for help, they had their journey and beginning. Be careful not to get caught up in someone else’s beginning – find yours and stick to what works for you.
Stay the Course
Vestibular disorder treatment is a long and often grueling journey. Finding something that will work for you can sometimes be daunting, but there truly are always options. You can always fire your doctor if they don’t listen to you. you are welcome to try something new if your think it will work for you. Do not give up – keep on pushing through, even on the hard days where it feels impossible.
Fatigue and exercise are a vicious cycle. This cycle often occurs when you do too much in one day, become exhausted, rest for a week, and exercise again. And the cycle repeats. Fatigue can happen for many reasons, many of which are due to a chronic illness. I understand that saying “you should just exercise more” to a person with chronic illness, and chronic fatigue is ableist, and I am not trying to preach that narrative. I will do my absolute best to explain how to exercise to prevent fatigue instead of triggering fatigue.
What is fatigue?
Fatigue is not being tired; it’s an entirely different feeling based on proper exhaustion. It is not because you haven’t slept enough, and no amount of coffee will make it better. Tired happens to everyone; we are tired after a hard workout, tired at the end of the day, and tired when we don’t sleep enough. Tired is not fatigue.
Fatigue is a constant and unrelenting form of exhaustion. Fatigue happens when our bodies cannot provide enough energy to function properly, let alone do our normal daily activities. This will ultimately lead to needing more rest than an average person and doing less movement overall. Our bodies love to move – we are meant to. But, if you can’t move as much as necessary, it leads to deconditioning.
Fatigue does not just come from being conditioned. Other chronic disorders, such as hypothyroidism/Hashimoto’s disease, chronic fatigue syndrome, myalgic encephalomyelitis, sleep apnea, POTS, kidney disease/organ failure, and other chronic illnesses can also be at the root cause of fatigue. However, most of these conditions, if there is too much rest involved, can lead to deconditioning, which is often the root of the issue.
What does Deconditioning Have to do With fatigue?
Deconditioning is a very complex physiological change in your body after a period of prolonged rest. This can happen as quickly as a week, but those losses are typically regained more easily. The deconditioning I am talking about occurs after months to years of not moving freely, walking, lifting, working out, or even consistently running errands. This will lead to a decrease in cardiovascular function, decreased muscle mass, and more.
Decreased muscle mass is what we are going to focus on here. A decrease in muscle mass can increase the risk of infection, decrease muscle strength & mass, increase the risk for comorbidities, increase the risk of death, and more. However, it would seem impossible to work out, move, and increase muscle mass with chronic fatigue, right? Well, not exactly. Strengthening, in many cases, is a primary key here.
How Strength Training Helps Fatigue
Fatigue stems from quite a few areas, as mentioned above. Still, for this article, we will talk about deconditioning as the source of fatigue, as deconditioning is a linchpin between all other conditions and fatigue. Your body can do a specific number of tasks each day, and your body needs the endurance to do all of those tasks. The strength of your muscles is a significant factor in fatigue. Your body needs to be strong enough cardiovascularly (heart and lungs) and musculoskeletally to provide your whole body the strength to get through a day with enough endurance not to run on empty and take energy from the next day by overdoing it.
Strength training works to combat fatigue by increasing your endurance. In this case, we are talking about muscle endurance, and although the science can get much more complex, it’s not necessary to understand how to combat it. You run around all day doing the same thing over and over, wondering why you become tired after a while. Becoming stronger, and working intentionally to strengthen the systems that are fatiguing helps improve your endurance. This is true for anything.
If you want to run a 5k race but can only run 1k right now, there’s no way you will run a 5k without training, right?
If you want to do a bicep curl with 15 pounds, but can only like 5 pounds right now, no amount of living your life the same way will help you get to that 15-pound mark.
This example can be said for anything, and it can be used to describe how strengthening your body will improve your ability to do your activities of daily living without extreme fatigue. You need to intentionally strengthen your system to be able to tolerate all of your activities.
Muscular strengthening programs, like Vestibular Group Fit, does this exactly. In this group, there is an opportunity for 6 days/week of workouts, which will strengthen your entire body. But cutting out 30-45 minutes of your day, a few times a week, you will be able to improve your overall endurance to be able to do more than you were previously. Your muscles will become stronger, your cardiovascular strength will improve, and you will be able to do more longer!
Energy Conservation for Fatigue
Energy conservation is planned rest and scheduled activity, which is helpful with chronic fatigue and chronic dizziness. Energy conservation is always helpful, with or without a fatigue dysfunction, but especially if you are becoming exhausted from activities that you used to not have any issue with. Energy conservation is the process of changing the environment or the task in order for it to match your energy levels and expenditure. Tactics like delegation, time management, task grouping, and interval rest are important to effective energy conservation.
Delegation
Asking for help where you need it is vital. People like to help, especially the people closest to us. Our loved ones are available to take on tasks when you don’t feel that you can. If you need extra groceries from the store, ask your partner to pick them up on the way home from work instead of making an extra trip out to get them. This helps conserve energy for when your whole family is home at the end of the day.
Time management
Manage your time in a scheduled way so you’re able to place high-energy tasks further apart from each other. When you have your day planned ahead of you, even if plans change, it will be easier to know what you can say yes and no to. If you’re having a day where you’ve managed to take a lot of time for yourself, and dinner plans pop up you will be able to say yes. It’s all about planning for what you need to do during the day, and not overdoing it into the next day.
Task Grouping
Grouping multiple tasks together that make sense together can be very helpful. Instead of making multiple trips out of the house daily, try making one trip for errands, but resting in between stores. You can take a break in your car or on a bench if you need, but you won’t have to drive both ways multiple times, saving you both time and energy.
Task simplification
As humans, we tend to overcomplicate things that should be simple. Try to buy precut vegetables, use grocery delivery services, sit to cook/clean/shower, and streamline your chores. The easier that all of these tasks are, the easier it will be for you to do more throughout the day! Really reflect on what you do day to day and try to implement simplification in at least 50% of them.
Interval Rest
Quit while you’re ahead. We tend to quit after we are running on empty and are feeling exhausted. In the photo below, the battery is slowly dying. Think of yourself like a battery that needs to be charged. Charging while you’re already partway charged is significantly more quickly than your phone’s battery dying and you needing to restart it. Rest before you absolutely need to charge. that means you may need a 15-minute nap or couch sit throughout the day. This is not something to be ashamed of; instead, be proud of yourself for listening to your body’s needs.
To decrease this fatigue overall, we need to strengthen your whole system. Taking time out of your day, every day, to schedule in simple strengthening exercises will build your battery so you will be able to be active longer without needing to stop due to fatigue.
Vestibular Group Fit has a Premium Content Module about fatigue. You will learn about prevention, energy conservation, treatment. And, the best part, is it can be completed from the comfort of your own home.
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Due to the complexity of migraine, and vestibular migraine, finding a treatment that works for you can seem impossible. However, with so much new migraine research, there is more evidence for new treatments constantly coming out. This is great, but can be hard to keep up with! One of the latest and greatest treatments for migraine are neuromodulation devices. That’s just a fancy word for electrical stimulation machines used to moderate headache and migraine attacks. The following devices can be either be used as treatments for preventative care, acute attacks, or both! Some have more research than others, and it’s not for everyone, however, anything that we can do to avoid migraine overuse headache and prevent migraine without pharmaceuticals is a win in my book!
Cefaly for Vestibular Migraine
Cefaly is by far the most popular new migraine-neuromodulation device I’ve seen recently. Patients love it, people all over Instagram love it, it gets all-around good reviews. I like it for a few reasons. The first is that they give a 90-day money-back guarantee. If you have migraine, you know by now that you need 90 days to determine if something work for you or not, and Cefaly provides that experience, because if it doesn’t work for you, you can send it back free of charge. Additionally, the first week is free, and it can be on a payment plan. Next, you don’t need a prescription. You can literally buy ti from Amazon and it will ship right to your door for a one-time charge. You do need to get new electrodes once in a while, but you can decrease the number you use by following the directions on the inside of the box to prepare your forehead correctly. The downside? there aren’t many, however, you will look like you belong in Star Trek or like you’re some sort of alien for an hour every day. It does prevent you from going out, unless you wear a big hat, or just don’t care that people might give you a funny look. Additionally, some people just don’t like the sensation, and therefore won’t use it.
The preventative mode is to be worn daily for 20 minutes, and an acute treatment is 60 minutes. You simply place it on your forehead, turn it on, and you’re good to go! You can even fall asleep with it on! In my opinion, it’s worth a shot!
eNeura: sTMS (Single-Pulse Transcutaneous Magnetic Stimulation) For Migraine
sTMS uses magnetic wave fields to pulse through your brain and soft tissue into your head to decrease the frequency of Migraine attacks. sTMS has been used for years, but the eNeura device is one of the first devices that can be used from home. You simply place it behind your head at the base of your neck and press a button to direct an impulse into your brain to prevent and treat migraine attacks. You will need to have a doctor prescribe it to you, so click here to find a doctor in your area who is familiar with the device and can see if it’s right for you.
Nerivio for Vestibular Migraine
Nerivio is used as a peripheral nerve stimulator in your arm to ‘confuse’ nerves in your brain to distract the pain from migraine. The message from your arm is sent to your brainstem and inhibits the pain signals from your brain stem that are causing the painful migraine. According to their research found on their homepage, 74% of people found it at least moderately helpful in relieving migraine pain. Additionally, it has an app that helps to track your migraine frequency and control the stimulation from your arm. You can wear it out, as it is on your arm instead of your forehead, and it will still be discrete. This one can be covered by your insurance, so if you’re looking for something that’s important to you, this may be a good fit!
GammaCore for Vestibular Migraine
GammaCore stimulates the Vagus nerve, which is the long nerve that wanders through your whole body. It affects your brain stem, heart, gastrointestinal tract, and more. GammaCore device is to be pressed against your neck, right next to where you can feel your pulse, for a specific duration of time. The biggest con to GammaCore is its price. The cost of GammaCore is about $200 every three months. This may seems expensive, however for some people it can reduce the number of other medications and hospital visits they may need to pay for. This would more than make up the difference. If it works for you it could absolutely be worth it! You do need a prescription to receive it, so ask your doctor!
Magnesium is an incredibly important supplement in our bodies, especially if we have migraine. Many studies have found that taking daily magnesium can help reduce migraine attack frequency and intensity. Typically the dose is 400-500mg/day for prevention, and then more for an acute dose if you’re trying to stave off an attack.
Types of Magnesium for Migraine
Magnesium Oxide
Magnesium oxide is the most common form of magnesium found in most stores, and if you pick up most drug store magnesium, it will likely be oxide. This is an affordable option and it’s in Class A of supplements, meaning it’s safe during pregnancy.
Magnesium Glycinate
Magnesium glycinate is the slightly less common form of magnesium, however its still easily accessible and does not cause the stomach upset that oxide does!
Magnesium Threonate
AKA CogniMag is something that many in the Vestibular Migraine community swear by for grain fog! IT’s a slightly different make up of magnesium and helps with improving cognition.
Magnesium in Foods
Many common foods are high in magnesium, and if you’d rather just try to eat enough throughout your day, you are welcome to try. The most common foods with high magnesium are beans/legumes, nuts and seeds, fiber-rich whole grains, dairy products, and many leafy greens. Although it’s entirely possible to get enough magnesium in your diet this way, it’s unlikely enough for a person with vestibular migraine, as a person with VM is typically low in magnesium, even if they eat a well-rounded diet.
Magnesium Spray
Magnesium spray is a topical form of magnesium that can help get magnesium into your bloodstream, without ingesting it orally. Because so many people are sensitive to magnesium in their gastrointestinal system, it’s not always an option to take it orally, even if you want to. A great place to start, other than your diet, are topical options! 4 sprays of this, on your skin, provides 66mg of magnesium! Although it’s a ways to get up to 400, it’s an excellent place to start!
Magnesium Lotion
Magnesium lotion, similarly to spray, is another topical option for you. This way, you won’t have gastrointestinal upset, but will still be able to increase the amount of magnesium your bloodstream absorbs. Additionally, it is a great way to practice self-massage on your neck. Take some of this cream, dab it on your neck, and rub your neck and shoulders for a neck-pain-relieving massage.
Magnesium Bath Soak
Sometimes when you are having a high pain migraine day, there’s nothing better than a warm bath. Pop this magnesium bath and foot soak in a bath of warm water and relax!
Magnesium Roller
The last option for non-oral magnesium is a roller. You can roll this anywhere on your body, it can sometimes help with sleep when put on your temples, or head pain relief!
Vestibular Migraine, as I’m sure you know by now, can be incredibly challenging to manage. Between weather changes, hormone changes, food triggers, and decreasing your caffeine intake, ‘a challenge’ doesn’t even begin to describe it. There’s a new study that I wanted to bring your attention towards, Dietary alteration of n-3 and n-6 fatty acids for headache reduction in adults with migraine: randomized controlled trial.
This article is interesting because instead of taking another thing out of your diet, it talks about something you can and should eat more of – finally!
What Food Group is Great for Vestibular Migraine?
This new study from the British Medical Journal shows that increasing Omega-3 Fatty acids, and without decreasing Omega-6’s can help decrease migraine pain, days, attacks, and other migraine-related symptoms.
The research shows that altering Omega-63s without changing Omega-6’s can decrease pain severity and frequency of attacks. However, the research did not find that there was a significant difference in quality of life.
What’s the Science between Omega-3’s and (Vestibular) Migraine?
Vestibular Migraine occurs due to a complex cascade of events that begins in the brain stem and trigeminal nerve, impacts the trigeminocervical complex, and then impacts the vestibular system. This cascade of events is what causes both pain (trigeminal nerve) and dizziness (vestibular nerve) in those with vestibular migraine. Omega-3’s are protective against that response.
As human beings, we are great at many things, however, synthesizing our own Omega-3 and 6’s is not one of them. Therefore, we can alter the number of fatty acids we have at any given time with our diet and/or supplements. And, it just so happens that these fatty acids are essential to the migraine cascade – in fact, they have a big role in pain regulation.
The nerve endings of the trigeminal nerve (the one that causes pain in migraine) are regulated by these same fatty acids, called lipid mediators. These mediators and together known as oxylipin receptors, and they’re enriched at the end of the trigeminal nerves. They regular sensitization and the release of the headache-related neuropeptide calcitonin gene-related peptide (1). This fact implies that there is a link between omega-6 & 3 fatty acids and headache etiology.
The oxylipins that come from Omega-6’s have been found to “sensitize the trigeminal nerve endings, and evoke behavioral pain responses;” this means Omega-6’s can increase pain severity and migraine frequency (1). However, the oxylipins that are derived from Omega-3’s are found to have antinociceptive properties, meaning that they reduce pain (1).
Where do I Find Omega-6’s, and Should they be Avoided?
Omega-6, the kind of fatty acid that is found mostly in the typical American diet, in fact, there is research to show that most people who eat a Western diet eat significantly more Omega-6s than Omega-3’s. Omega-6’s do play a role in our body’s function, so you should not completely get rid of this kind of fat. However, because we eat so much Omega-6, and want to try to fit in more Omega-3, it’s important to know where they come from.
- Vegetable oils
- Soybeans
- Corn/corn oil
- Eggs
- Some meat and fish
Where Do I Find Omega-3’s?
Omega 3’s are to kind of fatty acids we don’t get enough of in the Standard American Diet. It’si’mportant we get more of these than Omega-6’s so we can desensitize the trigeminal nerve, decrease pain severity, and decrease pain days overall. Although it may be easier for you to take them as a supplement, it is better to get them in your food, and more affordable. However, if you do not like any of these foods, it is typically recommended to get them in supplement form (aka Fish oil). Ask your doctor before you change or start a new supplement.
- Salmon, mackerel, or other fatty fish
- Seaweed and algae
- Chia and hemp seeds
- Walnuts
- Edamame
- Oysters & shrimp
- Spinach & Brussels
- Supplements
Source:
Ramsden, C. E., Zamora, D., Faurot, K. R., MacIntosh, B., Horowitz, M., Keyes, G. S., Yuan, Z.-X., Miller, V., Lynch, C., Honvoh, G., Park, J., Levy, R., Domenichiello, A. F., Johnston, A., Majchrzak-Hong, S., Hibbeln, J. R., Barrow, D. A., Loewke, J., Davis, J. M., … Mann, J. D. (2021, July 1). Dietary alteration of N-3 and N-6 fatty acids for headache reduction in adults with migraine: Randomized controlled trial. The BMJ. Retrieved October 5, 2021, from https://www.bmj.com/content/374/bmj.n1448.
When do you start vestibular rehabilitation therapy? That’s a big question that I get very frequently because starting Vestibular Rehabilitation Therapy can be a big decision. It’s a big commitment to yourself, it can be a big financial commitment, and parts of it can be difficult and uncomfortable.
Vestibular Therapy’s intention is to push you to the edge of dizziness and discomfort without making you too dizzy, to make you stronger. It’s a very fine line, and, if you’re not ready for it yet, it can make your symptoms worse. I say this not to scare you away from starting Vestibular Rehabilaition, but to prepare you for whatever may arise.
When Am I Ready for Vestibular Rehab?
Vestibular rehabilitation therapy can almost always be useful, but that does to mean it’s useful from day 1 of your diagnosed vestibular disorder. Vestibular rehabilitation is most effective when you are medically stable, and you are willing to feel a little bit dizzy during your exercises. Even if you are willing to put 100% effort into VRT, it doesn’t always mean you’re ready. You may not be ready to start Vestibular Rehab if a singular movement of your head makes you too dizzy to go about the rest of your day. In these cases, seeking help from a physician for medical intervention is a better idea for the time being.
All of that being said, I always think it’s a good idea to get an evaluation. That way, you can know if you are ready for VRT, you have the contact of a great physical therapist for when you are ready, and if you are ready, you can go ahead and begin!
What Should I Expect in Vestibular Rehabilitation Therapy?
Vestibular Rehabilitation Therapy is supposed to make you dizzy, but it is NOT supposed to ruin your whole day. A mild increase in dizziness is specifically intended to target your brain’s vestibular error system. It’s very important that you push into this error system in order for your brain to relearn what ‘normal’ feels like. Your vestibular system is receiving an incorrect
What to Look for in a Good Vestibular Therapist?
Finding an excellent vestibular physical therapist can be quite difficult. Vestibular Rehabilitation Therapy can be a long journey, and having someone on your team for the whole ride is important. Finding someone who you feel comfortable speaking to about your symptoms, who you feel like listens to you, and works to understand your symptoms.
Here are a few red flags:
- If your therapist/provider gives you a list of pre-made exercises that are not relevant or scaled to you
- If your therapist/provide gives you Brant-Deroff or Cawthorne Cooksey exercises without explanation
- If your therapist/provider does not listen to your complaints and/or does not make your appointment about you
- If your therapist/provider does not seem up to date about the research
- If your therapist/provider is not a vestibular specialist
- There are a few programs that provide excellent vestibular education, and it’s not education we get from our basic physical therapy education. Ask your provider what continuing education they’ve done to help prepare them to be a vestibular specialist
When Will I Notice a Difference in My Dizziness Symptoms?
Vestibular Therapy is incredibly effective. Typically, within weeks, you will be able to notice a difference! Most research shows that you can probably see a difference within 4-6 weeks, if not more quickly. This does not mean you will feel 100% that quickly, but it does mean you will be more functional, less dizzy, more balanced, and be able to run more errands without as much difficulty. Vestibular Rehabilitation should be all about function, if you aren’t seeing a difference in your ability to live your life comfortably, ask your physical therapist to change your program.
What About Telehealth?
I have found that my patients who do VRT via telehealth have been just as successful, if not more successful, than those who have done Vestibular Rehabilitation in person. This is because being comfortable in your own home, in a familiar place, and not getting dizzy on the commute to the clinic all make it easier to do your exercises. Although there is some benefit to being able to see a patient in person, I have not seen a difference in outcomes from the patients I used to see when I worked in a clinic, to the patients I see now via telehealth. It is incredibly powerful, and oftentimes more effective than seeing patients in person!
Are You Interested in Working With Me?
I offer Vestibular Rehabilitation Services in New York, New Jersey, California, Virginia, and Maryland via telehealth. It’s an incredibly powerful service, and all my patients have been very successful. To learn more, email me ([email protected]) or go to our Contact Us page and shoot me a message! I will report within 24 hours!
Are you located elsewhere?
Fid a Vestibular Therapist in the US: https://vestibular.org/healthcare-directory/
Find a Vestibular Therapist In the UK: https://www.acpivr.com/find-a-physio/
Physical therapy for vestibular disorders, Vestibular Rehabilitation Therapy, Vestibular Therapy, or VRT is one of the most impactful and effective treatments for people living with vestibular disorders. Just about all people with vestibular disorders, including Vestibular Migraine, Vestibular Neuritis & Labyrinthitis, Superior Semicircular Canal Dehiscence, Meniere’s Disease, Acoustic Neuroma (pre and post-surgical), and others, can benefit from Vestibular Therapy.
Vestibular Therapy is most common in the treatment of Benign Paroxysmal Positional Vertigo, BPPV. Treated with a Canalith Repositioning Maneuver, this kind of true-vertigo can usually be treated in 1-3 sessions of Vestibular Therapy.
In addition to treating BPPV, Vestibular Therapy aims to improve vestibular system strength. Symptoms of dizziness, lightheadedness, gaze instability, gait & balance abnormalities, and general fear of movement are just some of the symptoms Vestibular Therapy treats.
In general, we have a tendency to think of Physical Therapy as the treatment for musculoskeletal and neuromuscular disorders. While yes, physical therapy is incredibly effective for those with knee pain, who are post-stroke or need help returning to exercise postpartum, it is also incredibly effective in the treatment of Vestibular disorders.
Vestibular Rehabilitation Therapy Research
In clinical practice, I see Vestibular Rehabilitation Therapy change the lives of many people. Some people who haven’t been able to shower without a shower chair for more than 5 years can now comfortably stand in the shower and bathe. Others who have wanted to return to exercise but have been too nervous to move are now running long distances. Although there are many success stories similar to these, there is also research to back up these claims.
Vestibular Rehabilitation Therapy for Vestibular Migraine
Because of the lack of general research and criteria, there is no specific protocol to treat Vestibular Migraine, however, research does find that Vestibular Rehabilitation can improve Vestibular Migraine symptoms. Symptoms such as motion sensitivity, imbalance, spatial disorientation, and more are those we aim to treat. According to a 2009 study by Whitney, et.al., patients who have migraine attacks and migraine-related vestibulopathy benefitted from Vestibular rehabilitation Therapy, especially when combined with pharmaceutical management (1). Another article, a systematic review of articles, showed that Vestibular Rehabilitation Therapy was effective in treating subjective and objective complaints of vestibular symptoms.
Vestibular Rehabilitation Therapy is also found, in this 2017 article by Sugaya et.al., to improve headache symptoms, as well as symptoms of dizziness, and tension-type headache in those with vestibular migraine (3). All of this research, and more, can be found to show that vestibular symptoms of Vestibular Migraine can effectively be treated by Vestibular Rehabilitation Therapy.
Vestibular Rehabilitation Therapy for Unilateral Vestibular Hypofunction
A unilateral vestibular hypofunction is one of the most common causes of vestibular dysfunction and general disorientation and dizziness. This study sought to determine whether Habituation or Gaze Stability (AKA Adaptation), two common Vestibular Rehab protocols, was more effective (4). The research concluded that both were incredibly beneficial, and all treatment groups had positive outcomes. One treatment group used Gaze Stability exercises, and the other group used habituation exercises. After 6 weeks, both groups saw improvements in both habituation and adaptation outcome measures. This research shows, and otherwise cites, that the only ineffective treatment is to do nothing at all.
Vestibular Rehabilitation Therapy for Mal de Debarquement Syndrome
Mal de Debarquement Syndrome, or MdDs, is the sensation of rocking and swaying chronically, that gets better with passive movement and worse with being still. Classic Vestibular Rehabilitation Therapy is not very effective for the specific MdDS symptoms, but it does work to improve your balance and ability to walk. Your vestibular therapist could also help you with the Dai Protocol, which is the best possible treatment option for those with Mal de Debarquement syndrome.
What Else can your Vestibular Therapist Help you with?
A vestibular therapist cannot officially diagnose you with a vestibular disorder, however it’s really common that your vestibular therapist understands vestibular disorder diagnoses better than other healthcare professionals. Great vestibular therapists are typically vestibulo-holics (we LOVE treating dizziness). Not only will we help you return to gentle movement, but we can help empower you to talk with your doctor about a correct diagnosis, help you understand your vestibular disorder better, help you understand which supplements you may need to take, and more.
If you are a person who wants to return to the grocery store, driving, walking, cooking, and more without dizziness, Vestibular Rehabilitation Therapy with an excellent vestibular therapist can absolutely be of help to you!
When to Begin Vestibular Rehabilitation Therapy
Vestibular Rehabilitation Therapy is most effective when you are actually ready for it. But what does that even mean?
Vestibular Rehab is effective, the research shows that whether you have a unilateral vestibular hypofunction, Vestibular Migraine, or other vestibular pathology, Vestibular Rehabilitation Therapy should be a part of your recovery plan. However, starting before you are really ready for it can actually be discouraging and ineffective.
In my practice, I have found that VRT is most effective when my patients are in a sub-acute phase. This is mostly anecdotal, but you will find that better vestibular specialists don’t always refer patients to Vestibular Rehabilitation Therapy immediately after diagnosis.
There are of course exceptions, for instance, diagnoses like Vestibular Neuritis need immediate Vestibular Rehabilitation Therapy and should be referred to a PT quickly. Vestibular Neuritis is a form of unilateral vestibular hypofunction, and you can read more about it here. In this case, it’s important to get to VRT immediately to help your system recover. You will learn about why you’re feeling dizzy, what to do during a flare-up, and how to improve your vestibular system’s strength to increase gaze stability and habitation.
In Vestibular Migraine, however, it’s not always best to begin immediately. Vestibular Migraine patients can be incredibly delicate, and more movement in the acute phase can cause a worsening of symptoms. I evaluate many newly diagnosed Vestibular Migraine patients, and as much as I want to help them as quickly as possible, I send quite a few away for weeks to months at a time. It’s a hard line to walk because beginning to move more can be frightening at first, and you may never really feel ‘ready’. However, if you talk to a vestibular therapist, and your referring physician, there is usually an excellent plan of attack. It can’t hurt to get an initial evaluation from a vestibular physical therapist and then make a plan. Maybe you should start now, maybe you should start later – it’s always between you and your healthcare team!
Still not sure when or how to begin?
Start by finding a vestibular physical therapist here, ask for an evaluation, and see what the therapist has to say. If he or she feels like you are ready, and you are committed to starting, then I say go for it!
Or, if you reside in Maryland, Virginia, California, New York, or New Jersey contact me for a free 10-minute consult to see if we’d be a good fit!
Sources:
(1) Whitney, S.L., Wrisley, D.M., Brown, K.E. and Furman, J.M. (2000), Physical Therapy for Migraine-Related Vestibulopathy and Vestibular Dysfunction With History of Migraine. The Laryngoscope, 110: 1528-1534. https://doi.org/10.1097/00005537-200009000-00022
(2) Alghadir AH, Anwer S. Effects of Vestibular Rehabilitation in the Management of a Vestibular Migraine: A Review. Front Neurol. 2018;9:440. Published 2018 Jun 12. doi:10.3389/fneur.2018.00440
(3) Sugaya, N., Arai, M., & Goto, F. (2017, April 3). Is The Headache in Patients With Vestibular Migraine Attenuated By Vestibular Rehabilitation? Frontiers in Neurology. https://www.frontiersin.org/articles/10.3389/fneur.2017.00124/full.
(4) Clendaniel RA. The effects of habituation and gaze stability exercises in the treatment of unilateral vestibular hypofunction: a preliminary results. J Neurol Phys Ther. 2010;34(2):111-116. doi:10.1097/NPT.0b013e3181deca01
What’s the best workout for people with vestibular disorders? We get this question all the time here at The Vertigo Doctor, and our answer is always the same. Online fitness classes are an excellent way to workout if you have vestibular disorders, especially in the early stages of recovery when you might still be experiencing symptoms like dizziness and unsteadiness.
This guide will go over all of the reasons why online fitness classes, personal training, and general exercise are a great way to start living a healthy life again!
What is Vestibular Fitness?
While traditional workout routines focus on only muscular fitness, Vestibular fitness workouts focus on improving your senses of balance and movement, along with muscular and cardiovascular fitness. The more you learn about working out your vestibular system, the better equipped you will be to deal with vestibular stimuli and maybe even treat and prevent vestibular dysfunction.
Your vestibular system is designed to detect head and body movement and acceleration and help to keep you upright. Dysfunction of this system can lead to feelings of imbalance, dizziness, lightheadedness, and even vertigo.
Fitness is important for those with Vestibular disorders because research has shown that working out, whether intentionally or unintentionally, helps prevent dizziness flares and decrease the risk of acute vertigo episodes.
What Does Exercise do For the Vestibular System?
The vestibular system relies on movement for strength. Your vestibular system is a use-it-or-lose-it type system. The more you move, twist, turn, and play the stronger the system gets! Exercise does exactly that.
Exercising in the most basic form, walking really helps! Walking for 30 minutes/day does help to decrease dizziness and prevent attacks, however, moving in different planes and directions is even better for your system.
We know that the more we move, the stronger our muscles get. If you do enough bicep curls, for example, you will be able to see your arms become stronger and more toned. You can’t see your vestibular system, but you can feel its strength when you are less dizzy and more confident in movement. Vestibular Fit is the program we created to bridge that gap – completely virtual group exercise classes designed to strengthen your vestibular system without causing increased or excess dizziness!
Working Out at Home
Many people with vestibular disorders have trouble making it to fitness classes because of balance issues or nausea. For these individuals, working out at home may be a better option. That’s why Vestibular Fit and Vestibular Group Fit exist!
Working out from the comfort of your home may be better for you for many reasons:
- You do not need a gym membership. We all know these can be expensive, and many of us do not utilize all the services for how much we pay for the gym.
- You can participate without leaving your home, in a comfortable environment. Safety can be a big concern if you feel lightheaded or like you may fall over at any given moment. Workouts created to be in a safe environment and get your sweat on are vital to making sure you aren’t dizzy.
- You can fit it in anytime during the day. The best part about these workouts is that you can do them anytime during the day. Although group classes may be a good fit, you need to work them into your schedule instead of the other way around. With individual workouts that go at your pace and are made with your symptoms in mind, you can do them for any duration, at any time, and alter the workout as you see fit!
What Exercises are Safe for Vestibular Disorders?
This is a question I get asked a lot; are there better or worse exercises for Vestibular disorders? The answer is: it depends!
Confused? You’re not alone—many people with dizziness and vertigo avoid physical activity because they fear it will exacerbate their symptoms.
An amount of exercise that you can tolerate without excessive symptom exacerbation while still positively stimulating your vestibular and muscular system is a fine line to walk.
Right now, whether you are beginning to exercise or restarting, sprinting laps and going to spin class may be too much for you. It’s most important that you listen to your body. Starting slowly, even 5 minutes at a time, might be the best thing for you. I recommend people begin with timed walking and/or floor exercises.
Timed walking means you time yourself to see how you tolerate the exercise and work up from there. Starting slowly for all things is important. We especially know with Vestibular disorders – something is usually better than nothing, and beginning at YOUR beginning is personal to you and very important.
How to Improve at Home Exercises
Not everyone can get out and work out in a gym, especially with a vestibular disorder. Fortunately, there are plenty of great workouts you can do from home! Exercises like squats, push-ups, and bridges are fantastic exercises you can do from home. If your Vestibular disorder makes you feel unsteady on your feet when walking or standing up, use a countertop, table, or sturdy chair to support yourself. This will help prevent falls and ensure your safety. Exercise at home requires little more than willpower; it doesn’t need to be expensive or complicated!
Improving home exercise for those with Vestibular Disorders is why I created Vestibular Fit! Vestibular Fit intends to provide doable, scalable, and accessible exercises to help you get a workout without feeling dizzy.
What is Vestibular Fit?
Vestibular Fit and Vestibular Group Fit are fitness programs for Vestibular Warriors.
Vestibular Fit is a personal training program designed with you specifically in mind. Vestibular Fit’s workouts are changed every month and completely customized to your needs. Because it is personal training, the exercises are all 100% custom to your needs. Are you looking to return to running 5k’s? Let’s customize you a Return to Run program that focuses on your run speed, distance, and overall time!
Vestibular Group Fit is a group fitness program made for Vestibular Warriors – everyone else has fitness classes tailored to them, why not for dizziness and Vestibular strength? Vestibular Group Fit is a three-day/week group workout plan and 2 days a week of live workout classes. These classes will happen only once per day on workout days but will be available for 30 days after they’re published, then they’re stored in the Member’s Only Vault for access in the future! That way, if you can’t make it to live class, you will be able to work out with us on your own time!
Ready to begin?
We are SO excited for you to join the community!!
Vestibular Rehabilitation Therapy is the process of improving your imbalance, dizziness, vertigo, and other vestibular symptoms through exercise. To read more about the process of Vestibular Rehabilitation Therapy and how it works, click here.
How to Test Your Vestibular System
Your vestibular system can be tested in multiple ways, but there are a few tests and measures that I use most frequently in the clinic. These are the four most common tests that I find make people mildly symptomatic, and provide solid objective measurers that I can treat through Vestibular Rehabilitation Therapy.
The first measure I use is the Dizziness Handicap Inventory. This is a standardized scale that consists of 24 questions regarding your functional, physical, and emotional limitations surrounding dizziness and vertigo. It provides me as a Vestibular Physical Therapist an objective way to measure and track patient progress.
Next, I screen all of my patients’ ocular motor skills. I test visual tracking, visual range of motion, end range nystagmus, convergence, saccades, and for spontaneous nystagmus with and without fixation.
The Vestibular Function testing comes last in this order, as I need to be sure I check for central dysfunction before peripheral vestibular dysfunction. The next tests can check laterality of a vestibular lesion in some situation, gaze instability and use of Vestibulo-ocoular reflex, and your ability to cancel our your Vestibulo-ocular reflex.
1: Head Thrust Test (Head Impulse Test): this test can tell laterality of a vestibular lesion, usually after a Vestibular Neuritis, if the loss is 40% or more on one side. Ask the patient to stare at your nose, and quickly move your patient’s head left and right. If their gaze slips off their nose and you see a catch up saccade, that is the side of the vestibular lesion.
2: Dynamic Visual Acuity (DVA) Test: this test screens for gaze instability. You should start by reading an eye chart, the lowest line you can read comfortably. Next, your Vestibular Physical Therapist will shake your head right and left at 240 BPM in approximately a 60 degree motion. While your head is moving, you should read the chart again. This is scored by the number of lines between your static and dynamic head positions. A difference of three or more is clinically significant for gaze instability.
3: Vestibulo-ocular Cancellation (VORcX): this is a test for visual motion sensitivity via the cerebellum’s ability to inhibit the Vestibulo-ocular reflex. Standing, clasp your hands in front of you and place your thumbs up and together. Stare at your thumbs and swing your whole body and hands right and left, keeping your eyes on your thumbs the whole time. Repeat 10 times .While you are performing this motion, your PT should watch your eyes for saccadic eye movement, which indicates a positive test. Additionally, a positive test is if this makes you symptomatic.
4: Dix-Hallpike & Horizontal Roll Testing: these tests are for Posterior and Horizontal Canal BPPV. I only test for BPPV when my patients have a subjective history of rotary vertigo with position changes, or have other risk factors that make me curious. Because it’s easy to treat, and a quick test, I find it is usually worth my time to test most patients.
Best Vestibular Rehabilitation Therapy Exercises
The best Vestibular Rehabilitation Exercises will make you slightly dizzy, but not so dizzy that you feel faint, dizzy, or ill the rest of the day. Your symptoms should last a few seconds to minutes, and you should then be able to bring those symptoms back down to your baseline level.
Prescribing exercises for Vestibular Rehabilitation Therapy completely depends on what makes you dizzy. Your Vestibular Physical Therapist should perform a few objective measures, and also consider the subjective actions that make you dizzy.
Positive DVA Testing tells me as the clinician that you should begin VORx1 exercises (Vestibulo-ocular Reflex Times One). This will help with gaze stability. Other cues you may need VORx1 are: you have difficulty keeping your eyes focused in one place, you have the sensation that things “bounce” when you’re walking, or that you feel like you have a “lag” when you move your head.
- Stare at the pineapple in the center of the chart, and shake your head horizontally (the “no” direction) in a quick, small movement
- Perform this movement for 15 seconds as quickly as you can without allowing the pineapple to go out of focus or jump around.
- Stop, let your symptoms dissipate. Before repeating, your symptoms should return to your baseline (the level of dizziness you had prior to beginning this exercise).
- Repeat 3 times, resting completely back to baseline in between each set.
A positive VOR Cancellation Test means you should practice VOR Cancellation (VORcX) and/or being other visually stimulating environments. You can do this by performing VORcX as an exercise until you’re symptomatic and then performing grounding in between sets, or to simulate a stimulating environment you can walk into a busy environment, or watch something on a screen.
VOR Cancellation Instructions:
- Standing, clasp your hands in front of you and place your thumbs up and together.
- Stare at your thumbs and swing your whole body and hands right and left, keeping your eyes on your thumbs the whole time.
- Repeat until you are mildly-moderately symptomatic.
The Importance of Your Baseline
In between each repetition of a vestibular exercise, you need to return back to your baseline.
When your brain is already dizzy, and you’re performing an exercise to make yourself (briefly) dizzier, your fight or flight system is stimulated. We need to remind your brain that you are in a safe environment, that you can feel relaxed and calm in the face of dizziness. Because our brains are ‘plastic’, meaning we can teach ourselves anything, we can teach our brains to be stronger against dizzying stimuli.
Grounding is the answer to this in many ways. Grounding is the act is the act of feeling your stillness. Feeling your feel on the floor, your back in the chair, your arms on the armrests, and so on. Then, sit and breathe slowly, completely, and deeply. Be mindful of your surrounding and your stillness. This is a practice that can be meditative.
Return back down to your baseline dizziness level between each repetition. This is actually the most important part of vestibular exercises. Before restarting your exercises you should be absolutely sure that you’re feeling back to where you started!
Here’s a good rule of thumb for Vestibular Rehabilitation Therapy: no more than 5/10 symptoms over baseline, and for no more than 5 minutes at a time.
How to Dose Vestibular Exercises
Vestibular Exercises should be scaled, graded, and dosed based on your exact needs. Your Vestibular Physical Therapist should perform a test or provocative movement, and then see if you become symptomatic.
If you are symptomatic, stop, perform grounding, and then begin again when you’re feeling ready.
For VORx1 Exercises, I typically ask my patients to perform them 3 times a day for 15 seconds at a time. These can be all back to back 15s, grounding, 15s, grounding, 15s. Or, you can do one set each at breakfast, lunch, and dinner.
This is a good rule of thumb however no everyone can tolerate 15s, so if that is the case, I find a number my patient can tolerate and work up from there.
The same thing goes for all vestibular exercises. Find a level of movement that is difficult but tolerable, perform grounding, and then begin again.
Migraine and Vestibular Migraine can be reduced and managed naturally with vitamins, minerals, diet, and exercise! People often ask me which vitamin deficiencies cause migraine and if you should be tested. Although your doctor can test you, that’s not a requirement as most people with migraine do have issues with these deficiencies in most research. These vitamins include Magnesium, CoQ10, D3, Riiboflavin (B2), and Omegas!
Natural migraine treatments can be paired with your medical treatment, however, be sure you tell your doctor what you’re taking as some vitamins for migraine can have an impact on your prescription medication – there are always options, so its best to be safe!. Some people use natural migraine treatment alone, without the need for Here’s a list of vitamins and other accessible over-the-counter treatments you can try. As always, ask your doctor before you change or add anything to your treatment plan!
The most common supplements for Vestibular Migraineurs are CoQ10, Magnesium, and Riboflavin (B2). Some supplements, like Migralief have all 3 combined, which makes remembering to take it easier. However, sometimes just because it’s easier doesn’t mean it’s better – some of my patients have been very successful with taking Migralief, but others have needed to take each one separately for multiple reasons.
Magnesium for Migraine
Magnesium has so many purposes in our bodies. It helps with mental clarity, digestion, nerve function, blood sugar, and more! Taking keeping magnesium available in your body for use is called bioavailability. Different kinds of magnesium supplements help with different difficulties you may have related to migraine
Magnesium Glycinate
Magnesium glycinate is used for mental clarity and digestive health, without causing digestive issues or a crash at the end of the day. Glycinate is an amino acid that your body uses to fight inflammation and improve sleep. Magnesium glycinate also occurs in foods such as meat, dairy, and legumes. Since those on a Migraine Diet or Heal Your Headache diet may be avoiding most dairy and some legumes, glycinate may be lacking in your diet. It’s important we have all the necessary amino acids in our diets, so a magnesium glycinate supplement may be a great idea for you!
Magnesium Threonate
Magnesium L-Threonate is when we combine threonic acid and magnesium. This form of magnesium is a formed to be easily digestible and is great for mental clarity. Studies have shown that it helped promote learning and memory, and helped prevent memory decline. Threonate is already present in some level in our cerebrospinal fluid, and the presence of extra in neuronal cultures “increased functional synapse density” (2). Really good Magnesium Threonate, like the kind form Pure Encapsulations, is really hard to come by. If you can’t find it from Pure Encapsulations on Amazon, they have another show online here.
Magnesium Citrate
Magnesium Citrate is often used for treating digestive issues, such as constipation. Magnesium citrate is the most available form of magnesium – this is the kind of magnesium that you find generically in stores. This form of magnesium is also commonly found in powder form. If you have trouble with the bathroom in general and are a person who deals with chronic constipation it might be good to take Magnesium Citrate. However, if you do not, be more cautious about this – you might spend a little extra time in the bathroom than you had intended if you take Magnesium Citrate.
For more into on forms of migraine, you can take, click here!
Coenzyme Q10
Coenzyme Q10, or CoQ10, for migraine is used for preventing oxidative change in your brain. Migraine Brains hate change – so preventing large changes in oxidative stressors within your brain will help decrease the number of migraines in your life. CoQ10 helps support mitochondria by creating adenosine triphosphate, which helps us with energy (3, 4). Some studies have shown that CoQ10 can help with episodic migraine prevention up to 15 episodes per month. CoQ10 is made by Pure Encapsulations, like Magnesium, in pill form which is of high quality. It is also in chewable gummies made by NOW Supplements which patients have reported is effective as well.
Riboflavin (B2)
Riboflavin, which is a form of B2 vitamin, is effective in preventing migraine (5). Migraineurs are frequently B2 deficient, so supplementing your body this vitamin can be incredibly helpful in migraine prevention. Riboflavin is generally well tolerated, affordable, and will likely make you feel better. In the study, of people who took Riboflavin for the 3 month trial, 59% reported decrease in migraine symptoms by at least 50%. Riboflavin is useful in brain function, skin cell production, gut/digestive lining, and more. People who have migraine are typically deficient in B2, so it’s a good idea to supplement it into your diet. B2 can be found in eggs, milk, meat, nuts, enriched flour, and more If you do not tolerate these foods well, especially if you’re on a strict migraine diet, it could be a good idea to supplement it in vitamin form instead of trying to eat enough throughout your day. The typical dose is 400mg/day for at least 3 months, but as always, ask your doctor for more information!
It is significant, however, that riboflavin has been shown to interact with some medications like antidepressants and some cancer drugs, so be sure to check with your doctor first!
Omega-3 For Vestibular Migraine
A new study found that having more omega-3’s than omega-6’s is helpful for preventing pain and migraine frequency/days. We have two main forms of Omega-fatty-acids in our bodies. The first is Omega-6 and the second is Omega-3. Omega-3 has long been known to be healthier and better to have more of in your body. You can find it in avocados, fatty fish, and other nutrient-rich foods. Its other form is Omega-6, and is known not to be as healthy. This study found that increasing the number of Omega-3’s a person had, without doing any alteration of Omega-6, decreased headache frequency. Both Omege-3 and -6 are not synthesized internally, meaning that we have to eat them to get them in our bodies, or we have to supplement them or eat them!
Melatonin for Vestibular Migraine
New research shows that melatonin could be very helpful in treating vestibular dysfunction. MT1 receptors interact with melatonin, and are found all over the same parts of the brain that the vestibular system is! This study says “melatonin has been proposed as a prophylactic agent in the prevention of migraine attacks, a condition that can be associated with vertigo” (8). This study also states that in animal models melatonin has been found that it can be otoprotective (protective for the ear). 3mg was taken daily during this study, and it should be taken at night before you go to bed. This way you can not feel extra sleepy during the day.
Vitamin D3 for Vestibular Migraine
Vitamin D3 can be helpful in preventing vestibular migraine, but the mechanism is not clear. There is not a lot of evidence to recommend it to all patients with migraine or vestibular migraine, but it’s great to ask your doctor if it’s a good fit for you. Many people are vitamin D3 deficient, especially with migraine. There is some evidence to show that there is a decrease in migraine frequency and pain when vitamin D3 is supplemented. This is especially important when it is not sunny outside, or if you live in a particularly foggy place! We get D3 via UV waves, but if we don’t live in a sunny place, or you live in a house/apartment without a lot of light, it’s important to find a way to get it in. Supplementation is frequently the answer here!
Sources:
(1) https://www.healthline.com/nutrition/magnesium-types
(2) https://pubmed.ncbi.nlm.nih.gov/27178134/
(3) https://www.verywellhealth.com/coenzyme-q10-migraine-prevention-1719853
(4) https://www.migrainetrust.org/living-with-migraine/treatments/supplements-and-herbs/
(5) Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology. 1998 Feb;50(2):466-70. doi: 10.1212/wnl.50.2.466. PMID: 9484373
(6)Wolff, A. (2020, April 5). The Best Magnesium Supplements for Migraine. The Dizzy Cook. https://thedizzycook.com/magnesium-supplements-explained-which-one-is-best-for-vestibular-migraine/