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/
Learning to live with Vestibular Migraine is a life-long process, but tips and tricks from those with Vestibular or other forms Migraine can be so helpful. However, it is sometimes hard to find an all inclusive list of things that people have found helpful in the past. This is a list, which will be continually updated, containing items that patients have found to be helpful!
Lifestyle:
Allay Lamp
The Allay lamp’s intention is to decrease migraine triggers by emitting a calming green light that is proven to decrease photophobia, anxiety, and stress. We know that there are many wavelengths of light, which make up the whole world of colors, but for those with Migraine most of those lights are intolerable. Wearing migraine glasses is one solution, but another is to use this lamp. This lamp triggers small electrical responses in your brain, instead of large electrical signals that most bands of light cause. You can dim it, place a shade on one side for decreased light overall, or change it to a whiter light that is still soothing.
Migraine Glasses
There are so many pairs of glasses my patients have found to be helpful. Migraine glasses are intended to block blue light, in addition to yellow and other waves of light. Blue light ranges from 400-750nanometers. Because it is such a wide range, different kinds of blue lights are more and less problematic for your migraine and related symptoms. Some blue light glasses block only some parts of the blue light spectrum, even the parts that are good for you. Blue light around 460-500nm is actually healthy – we use blue light to monitor our melatonin levels, which affects our sleep-wake-cycle. Blue light can even be used to treat Seasonal Affective disorder. Blue light below 430nm is the “bad” blue light. The intention for a good pair of blue light blocking glasses is to block the blue light under 430nm. Special migraine glasses, like Theraspecs and Migraine Shields, and AxonOptics glasses do just that!
TheraSpecs
Theraspecs are the pair of glasses I let patients use in the clinic. I really like them as the pink hue from the FL-41 glasses are soothing for many of my patients, and they were created by a person in the Migraine Community. According to their website, TheraSpecs wearers experience 74% fewer migraine attacks on average per month, which for people with photophobia (light sensitivity) will make a huge difference. Even if you aren’t sensitive to light, Theraspecs will make a difference!
Theraspecs work to block the harmful blue light waves, provide wrap around protection of your eyes, and focus on blocking blue light the most at 480nm, the most aggravating wavelength for those with Migraine.
Migraine Shields
Migraine Shields are the best pair of glasses if you don’t want any color distortion in your vision. Most migraine glasses have FL-41 lenses, which are tinted pink – Migraine Shields uses a slightly different technology and aren’t tinted pink. These are great for work environments, using the computer, or choosing anything where color might be important. Migraine Shields do not come in a large enough size to fit over other glasses if you have a prescription! However, Migraine Shields have just released readers. These readers come in many shapes, sizes, and are so much cuter than the ones you find at the drugstore – these really multitask and are SO helpful!
AxonOptics
AxonOptics are also a great option for Migraine relief. They are not too pink, lightweight, and come in three different tints. AxonOptics glasses have three tints for three intentions: indoor, outdoor, and transitional. Transitional lenses take a little longer to make, and they are a little more expensive. However, if you are going to purchase 2 pairs anyway, it may be worth it.
Research has found that FL-41 lenses need to be specifically made for people with light sensitivity. AxonOptics creased their specific glasses for Migraine by crafting a lens that is consistent, effective, and a nice color. Additionally AxonOptics has a plethora of frames you can choose from, and an option for contact lenses.
These can also be in the form of prescription eye glasses – if you’d like them to fill your prescription they can do that so you can still be working with these on!
Why Not Just Wear Sunglasses?
Sunglasses, while they may provide relief for your migraine in the moment, block too much light. If light is a trigger for you already, you don’t want to make it an even bigger trigger than it is already. When you wear sunglasses all day, inside and outside, it blocks many wavelengths of light, not just those in the blue light spectrum which work to block the provocative forms of blue light. If you block many kinds of light, not just the ones that typically affect migraine, you may end up sensitizing yourself too all light, making your triggers worse!
Headache Hat:
The headache hat is a tool you can use to soothe the headache part of your Vestibular Migraine, if you have them. I have found that patients in the middle of an attack will get their headache hat from the freezer, and feel at lease some relief. I would put the entire thing in the freezer, so you don’t have to deal with putting it together when you’re in the middle of a Migraine attack. It’s an easy, natural, way to give yourself a little relief.
Food and Beverages for Vestibular Migraine:
Imperfect Foods Subscription:
Imperfect Foods is a weekly delivery of produce, meat, dairy, and snacks that is completely customized to your liking. You can choose what you’d like to go into the box, and they’ll deliver it to you on a set day for your whole neighborhood. I love Imperfect Foods, as they deliver the food that would normally be thrown out by grocery stores – your produce sometimes looks funny or misshapen, but is perfectly consumable!
They have options for organic or non-organic, and many other fun products that will make your life easier for when you really don’t want to go to the grocery store!
Click the link above, or here, for $20 toward your first week!
Ritual Zero Proof:
Ritual Zero Proof is a whiskey, tequila, or gin alternative that tastes like the real thing, but without the alcohol! It really does taste like the real thing, but has no alcohol, no hangover, and no migraine! This was started by three people who do drink but wanted an additional way to enjoy a cocktail that wouldn’t give them the tipsy feeling. Although not intended for a vestibular migraine diet, it fits perfectly into your lifestyle!
PureWine Wands: Sulfite Removers
Sulfites and histamines can be part of your trigger load. Because wine, and other food & beverage categories, can contain quite a few sulfites finding ways to avoid, or remove, the sulfites is helpful! PureWine Wands remove the sulfites from the wine, which are produced by the grape skins during fermentation, and naturally occur in almost all, if not all wines. Removing these will help, but make sure you follow the directions as they do have to sit for a while to be effective.
You can use the wands, for a glass of wine
Or the wave for an entire bottle!
Books for Vestibular Migraine:
There are a few books that Migraine patients should read, whether you have Vestibular Migraine or another kind of migraine. These will all help you understand Migraine and how to manage your symptoms
Victory Over Vestibular Migraine:
This book is by well-known neuro-otologist, Dr. Shin Beh. He goes through the steps from finding out you have Vestibular Migraine to learning what to do next in order to manage your Vestibular Migraine symptoms. This is an absolute must-read for all vestibular migraine patients – either if you have a new diagnosis or you’ve been managing your symptoms for a long time.
The Migraine Brain:
This was the first Migraine book I read when I started treating patients with Migraine. It really helped me understand the vastness of triggers a person can have, how to manage the symptoms, and what a migraine actually is. It’s around 300 pages, but it’s a quick read and it has charts in the back to help you analyze your migraine!
Heal Your Headache (The 1-2-3 Program for Taking Charge of Your Headaches)
This book will give you a step-by-step guide for dietary recommendations for migraine and vestibular migraine. It will take you through the elimination and reintroduction of foods into your diet for a successful migraine lifestyle!
This is a short list of many Vestibular Migraine Hacks that will help make your lives easier! Check back soon for more helpful products and tips as this list grows!
When you are diagnosed with a vestibular disorder, you may be prescribed a pharmaceutical by your physician. These can either control your symptoms, or treat the dysfunction at its core. Vestibular suppressants work to suppress your system to decrease the uncomfortable symptoms of dizziness, motion sickness, and vertigo. Vestibular suppressants are in three drug classes: anticholinergics, benzodiazepines, and antihistamines. Other pharmaceuticals like steroids and diuretics are also prescribed for different vestibular disorders and work to treat the cause of your symptoms. Everyone has different symptoms and different needs for medications, so the following is a very brief overview of medications I find are most commonly prescribed with vestibular disorders. Always be sure to talk to your physician and pharmacist before starting, stopping, or changing a medication.
Benzodiazepines – these are medications typically used for anti-anxiety and antidepressant purposes. However, they also act as vestibular suppressants and work to reduce dizziness in many vestibular disorders by reducing anxiety and motion sickness symptoms. Taking these for long durations should be avoided to decrease risks of lasting side effects like impaired memory and increased risk for falling (1).
Antihistamines – these are medications like meclizine and diphenhydramine (Benadryl). These help prevent motion sickness and reduce vestibular symptoms when you are having a dizzy spell. They are only effective in treating the symptoms, not the root cause of your dizziness.
Anticholinergics – these are medications that inhibit the firing of the vestibular nucleus and reduce vestibular nystagmus(1). Common anticholinergics are meclizine and scopolamine.
Diuretics – diuretics are prescribed to keep your sodium and fluid levels stable. Diuretics can be used for many purposes, but they’re prescribed to treat combat vestibular disorders such as Secondary Endolymphatic Hydrops. Those who are unable to treat their symptoms conservatively with a low sodium diet often use this as the next step in treatment.
Betahistine – this drug is prescribed to those who have been diagnosed with Ménière’s Disease (1). This is a medication that controls Ménière’s Disease by taking it daily. It tends to reduce the number of attacks, but usually doesn’t prevent them all together (2). It is very important you discuss this medication with your physician prior to beginning treatment, and taking it exactly as advised.
Steroids – steroids are prescribed to individuals with vestibular neuritis or labyrinthitis. Steroids are effective in treating both of these in the first 24 hours of symptom onset. They are used to effectively reduce swelling and edema on the vestibulocochlear nerve and lead to positive long term recovery compared to those who did not get the treatment within 24 hours (3). Taking these for extended durations can lead to loss of bone density and other negative effects, so be sure you’re talking with your physicians before you start, stop, or change medications!
Antiemetics – these work to control nausea and vomiting. Commonly prescribed antiemetics and Zofran and Decadron. Taking medication like this is sometimes recommended during a treatment for BPPV to prevent nausea; talk to your physician to discuss your options!
Meclizine – this medication is prescribed very frequently to suppress the vestibular system, to reduce nystagmus and vertigo symptoms. Meclizine is an antihistamine and an anticholinergic. These decrease nausea, prevent motion sickness, and reduce vestibular nystagmus. Clinically, I find that this is the most commonly prescribed medication by physicians for dizziness when symptoms first begin.
Zofran – this mediation is an antiemetic. This is prescribed to treat nausea in patients with vertigo and dizziness symptoms.
Sources:
(1) Yacovino, D. (2020, September 10). Medication. Retrieved September 17, 2020, from https://vestibular.org/article/diagnosis-treatment/treatments/medication
(2) Stewart, M. (2019, May 16). Betahistine information. Betahistine side effects. Retrieved September 17, 2020, from https://patient.info/medicine/betahistine-tablets-serc
(3) Sjögren, Julia; Magnusson, Måns; Tjernström, Fredrik; Karlberg, Mikael Steroids for Acute Vestibular Neuronitis—the Earlier the Treatment, the Better the Outcome?, Otology & Neurotology: March 2019 – Volume 40 – Issue 3 – p 372-374 doi: 10.1097/MAO.0000000000002106. https://journals.lww.com/otology-neurotology/fulltext/2019/03000/steroids_for_acute_vestibular_neuronitis_the.21.aspx
Vestibular Rehabilitation Therapy
Vestibular rehabilitation therapy (VRT) is a specific type of treatment designed to improve symptoms related to the inner ear, also known as the vestibular system. Research has shown that VRT can decrease vestibular symptoms and help you return to your normal activities. A physical therapist will determine if you will benefit from VRT and select exercises based on your specific needs and goals (1).
Common vestibular symptoms are:
- Dizziness
- Imbalance
- Motion sensitivity
- Ringing in the ears (tinnitus) or changes in hearing
- Ear fullness or ear pressure
- Nausea or vomiting
- Fatigue
- Difficulty concentrating
- Anxiety
- Depression
What should I expect?
A physical therapist will ask you questions to gather a history of your condition and lead you through a physical exam to determine if VRT is appropriate for you. Most treatment plans consist of a home exercise program and meetings every 1-2 weeks with your physical therapist to progress exercises, answer questions, and address any new changes. Your therapist may also suggest seeing other providers such as an ENT, audiologist or neurologist to best treat your condition. You may need to be seen for only 1-2 weeks or you might need to be seen over a course of 3-4 months, depending on a variety of factors (2).
Why does VRT work?
Your brain receives information from your vision, sense of touch, and inner ear to know where your body is in space to stay balanced. Certain events can weaken the connection from your inner ear to your brain, changing the information your brain is receiving. At first, your brain has difficulty processing this new information, resulting in increased symptoms. Based on a concept called neuroplasticity, your brain is able to form new connections and adapt to new information. VRT exercises encourage brain adaptation by strengthening the connection between your inner ear and brain. As your brain forms new connections and learns to correctly interpret sensory information, your symptoms will begin to decrease(1,2) .
To retrain the brain and encourage adaptation, VRT exercises will recreate or slightly increase symptoms, followed by a short recovery period to let symptoms return to normal. This is needed for your brain to learn that it’s safe to move without producing symptoms. As you improve, it will take more challenging exercises to elicit symptoms until you are able to participate in daily activities symptom-free (2).
How long does it take to recover?
Recovery is very dependent on you. Recovery can take 1-2 weeks or 3-4 months depending on personal factors such as diagnosis, lifestyle habits, medications, or additional medical conditions. An important part of recovery is regularly performing home exercises. Typically, after 1-2 weeks of regularly performing home exercises, you will notice a change as your brain begins to adapt.
Will my symptoms return?
You may experience a flare-up of symptoms after an illness, surgery, increased stress, dietary or medication changes, allergies, or other causative factors. If you experience a change in your symptoms, talk to your physician and physical therapist to reevaluate your condition and provide recommendations. Typically your symptoms will be less severe than the initial event, allowing a faster recovery (2).
15-minute rule
If it takes more than 15-20 minutes for your symptoms to return to normal, either during prescribed exercise or daily activities, that is a sign the activity was too intense. Next time you’re performing that activity, take frequent breaks to check your symptoms and allow for recovery as needed. This will continue to help retrain your brain.
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/
Sources:
(1) Cabrera King, Christian M, and Ronald J Tusa. “Vestibular Rehabilitation: Rationale and Indications.” Pub Med, Sept. 2013, www.researchgate.net/publication/256931442_Vestibular_Rehabilitation_Rationale_and_Indications.
(2) Farrell, Lisa. “Vestibular Rehabilitation Therapy (VRT).” VeDA, 25 Aug. 2020, vestibular.org/article/diagnosis-treatment/treatments/vestibular-rehabilitation-therapy-vrt/.