Q&A with the Vertigo Doctor

This article is hosted by a guest! Read as the Vertigo Doctor, Dr. Madison Oak, answers questions submitted by YOU about Vestibular Migraine and other vestibular disorders.

Hi, my name is Dr. Oak, though you might know me as a doctor. I am a Vestibular Physical Therapist. This means I am a PT who focuses on treating all vestibular disorders including Vestibular Migraine, Vestibular Neuritis, BPPV, and more!  Both migraine and vestibular disorders are incredibly diverse and complex, which makes being a vestibular specialist important to those with vestibular disorders. Symptoms vary so much from one person to the next. Finding an individualized treatment plan for each of my patients is both the most important part of my job, and my favorite part of my job! 

Vestibular Migraine is a central nervous system disorder; a form of migraine that causes vertigo and/or dizziness. You can have vestibular migraine with or without corresponding pain, aura, or other migraine symptoms. Your migraine attack symptoms can be incredibly variable, but approximately 40% of people with migraine also have vestibular symptoms during an attack (VEDA). However, just because vestibular symptoms are present does not mean you always have vestibular migraine, although you may have a vertiginous or dizzy component of your migraine. There are specific criteria to meet the diagnosis, which we will discuss, as well as how to differentiate between dizziness and vertigo, and other common questions! 

Let’s break down some common questions about Vestibular Migraine. 

What is the difference between dizziness and vertigo?

The two terms, dizziness and vertigo, are frequently used interchangeably. However, one is an umbrella term, and the other has a very specific definition.

Dizziness is the umbrella term with multiple meanings; it can mean lightheaded, heavy-headed, floaty, the feeling of a muddy brain, cloudy, foggy, or just generally off.  Because everyone experiences dizziness differently, it’s important that the terms are defined by you. Not only will it help you to understand your symptoms better, but you also might be able to communicate with your healthcare providers more easily. 

Vertigo is the specific and incorrect sensation/perception that you are moving, or that the room is spinning around you. Vertigo can occur in a variety of situations. The most common being caused by an episode of Benign Paroxysmal Positional Vertigo; this is when you have a mechanical inner ear issue and the world spins with position changes, usually in bed. 

Vertigo can also occur with Vestibular Migraine attacks. During a Vestibular Migraine attack, you may feel imbalanced, foggy, tired, fatigued, and/or have a bout of vertigo. Room-Spinning Vertigo occurs because involuntary eye movements, called nystagmus, which occurs when you have a dysfunction in your vestibular system, causing your eyes to move. Typically, this sensation is short lived, although when it stops, it may leave you feeling imbalanced and uncomfortable. 

Can someone develop VM after living with just head pain?

Yes! The most common, and simplest way, to diagnose Vestibular Migraine is from a person who has a history of migraine that is now getting vestibular symptoms as well.

Here are the criteria for Vestibular Migraine according to the International Classification of Headache Disorders: (Hilton)

  • At least 5 episodes of vestibular symptoms of moderate to severe intensity lasting 5 minutes to 72 hours
  • Current or previous history of migraine with or without aura according to ICHD classification
  • One or more of the following migraine features with at least 50% of the episodes:
    1. Headache with at least two of the following characteristics:
    2. One-sided location, pulsating quality, moderate to severe intensity; photophobia, phonophobia
    3. Visual aura
  • Not better accounted for by another ICHD diagnosis

Migraine changes throughout your life. Your symptoms of pain may change, you may develop new triggers or lose old triggers. Vestibular symptoms are on the list of symptoms you can develop, or always have. If you think you are starting to get migraine symptoms after having painful migraine attacks, without vestibular symptoms, throughout your life, be sure to talk to your neurologist! 

Tell me about VRT. When should I do therapy, how does it help, and can I do it on my own or do I need a virtual therapist? 

Vestibular Rehabilitation Therapy, or VRT, is the best way to treat chronic symptoms of vestibular disorders that have resulted from acute migraine attacks. Finding a Vestibular PT can be difficult, as many physical therapists are not trained in vestibular disorders. Finding a PT that has focused on Vestibular Disorders is important because the treatment can vary so much from person to person. Most physical therapists learn about Vestibular Therapy for 1-2 hours in PT school, and then don’t think about it again. Seeing a PT who does not specialize in vestibular disorders is like seeing an orthopedic specialist for a neurological problem: the orthopedic doctor may understand what you’re going through, but the neurologist will be able to help you more accurately. 

Because not everyone lives somewhere where a Vestibular Therapist is accessible, teletherapy is an excellent option! Telehealth, and teletherapy is a great way to receive Vestibular therapy. Your visit should look very similar to an in-person visit, you will talk about your diagnosis, symptoms, aggravating factors, easing factors, and all about you!

As a Vestibular PT, my patients and I take the time to figure out exactly what causes symptoms, what their symptoms are, how to decrease symptoms, and what their goals are. I do the exact same thing in an in-person visit as I do in a telehealth evaluation. These include: vestibulo ocular reflex testing, walking with head turns, balance strategies, and other functional movements!

VRT is most effective when a trained Vestibular Therapist is able to help you create a program customized to your exact needs, either via telehealth or in-person! If finding a vestibular therapist in your area is difficult, try using VEDA’s search function to find someone licensed in your state. Reach out and ask if they do telehealth – usually the answer is yes! 

Tips for everyday dizziness or vertigo?

Having dizziness and vertigo daily can stem from a few different root causes. Getting down to the true reasoning you’re having vertigo or dizziness is important. At the top, we discussed the difference between dizziness and vertigo. Distinguishing between the two is important when you’d like to know how to fix the problem. 

  1. If it is truly daily vertigo, and the room is spinning when you change positions, you should be evaluated by a Vestibular Physical Therapist for BPPV. This can be treated in a few visits usually. It’s important that a Vestibular Therapist helps you to diagnose and treat this condition. Those with Vestibular Migraine are at a higher risk for BPPV, and so being sure you have a go-to person for treatment is important.
  2. Track your symptoms. Whether your diagnosis is Meniere’s Disease, Vestibular Migraine, or anything else, figuring out what is causing your dizziness is important. Keep a log in your phone, if you are somewhere and quickly turn, or walk down a busy road, or you’re on a long drive and something makes you feel dizzy, write it down. Tracking these symptoms will help you to know what to work on. 
  3. Vestibular Rehabilitation is always my most valuable recommendation. Vestibular Rehabilitation Therapy treats more than just BPPV. VRT treats dizziness, imbalance, fear avoidance of movement, and other symptoms of BPPV. 
  4. Grounding. Grounding is the concept of feeling your stillness, calming your nervous system, and deeply breathing for a few minutes when you feel dizzy. Calming your nervous system will help you start to feel better and teach you that you and your body are safe and can do a motion calmly, without feeling dizzy. You can do this laying down, in a chair, or standing on a wall. 

How can I do things like hiking and more vigorous exercises?

Vigorous Exercise can be one of the most difficult things to build up to with Vestibular Migraine, or any kind of Migraine. Too much exercise can cause a Migraine attack if exercise is a trigger for you, and not enough exercise can cause an attack as well. Finding a happy medium is very important. 

When it comes to exercise, 30-minutes per day is what you need for health and Migraine attack prevention. This can be walking, vigorous cleaning, biking, or anything else that gets you up and moving your body. 

If you would like to begin vigorous exercise, the important thing is to slowly ramp up rather than do it all at once. Do this over a weeks or months time span. 

If you want to hike, start with long walks. As you find that becoming easier, find a hill in your neighborhood and walk up it a few times. Do this until you’re comfortable with hills. Next, find a more rugged hill, which would be a short hike and begin walking there. Slowly progress in this fashion until you’re comfortable hiking. Do not push yourself too far in one day. Be sure to slowly work your way up to each level of tolerance before progressing to a new height. 

If you want help with this, Vestibular Fit may be the right program for you! At Vestibular Fit, we build customized workout programs that fit your exact vestibular needs. If you want to learn more about Vestibular Fit, please DM me @thevertigodoctor on Instagram, or via the “contact us” form on my website

How can I address rocking and dizziness sensations?

Rocking, swaying, and dizziness are among the most irritating and chronic symptoms that Vestibular Migraineurs experience. If you have Vestibular Migraine and the rocking sensation is the most irritating symptom, I would recommend vestibular therapy for treatment. Vestibular therapy, while it may seem like my answer to everything, truly is one of the most beneficial things you can do for yourself. 

The rocking and swaying sensation are an incorrect perception of where you are in space. Everyone moves constantly. Moving at your ankles and hips are actually balancing strategies that all humans employ. These strategies help us stay upright by knowing where we are in space, and help us overall. 

People with chronic dizziness frequently become hyper aware. Aware of where you are, what feels wrong, what may feel right, feeling dizzy, feeling hungry or full, feeling imbalanced, feeling  anxious or overwhelmed. 

All these feelings are real and completely valid. I want to make it clear that just because you feel a swaying does not mean you’re making up your symptoms. However, your sympathetic (fight or flight) nervous system may be overreacting to normal stimuli; this can make you feel rocking, swaying, or other abnormal sensations. Along with Vestibular Rehabilitation Therapy, cognitive behavioural therapy, psychology, and psychiatry can be very helpful. 

Are there sleeping positions that help? 

Sleeping when you have a vestibular disorder can be difficult. The two most common problems I hear about are: Positional Vertigo, and the sensation of floating when you’re in bed at night. 

If you are having true vertigo when lay down, Benign Paroxysmal Positional Vertigo (BPPV) is most likely what’s going on. BPPV will trigger vertigo too occur when you lay down or change positions, like rolling over in bed. If you are having a BPPV attack, and you don’t want to trigger your symptoms before you get treatment, you should sleep with your head slightly elevated. Elevating your head will remove your head from the plane posterior canal (which is triggering the vertigo). If you have horizontal canal vertigo, this is a little more difficult. You will trigger the vertigo in about 30* of neck flexion (like a chin tuck). But, propping your head up more than 2 pillows will help you be more comfortable until you seek treatment from a Vestibular Therapist. To find a Vestibular Therapist that can treat your BPPV check out VEDA’s website!

If you feel like you’re floating away from your body when you’re trying to fall asleep, grounding will help. Start by laying on your back in a comfortable position. Then, beginning at your heels, think about each part of your body that’s touching the bed. Feel how still your body is. Remind yourself that you are not moving, you safe, you are in bed, and your back is flat on the bed. Really try to focus on each individual body part you have touching the surface, and simultaneously focus on your breathing. 

I frequently suggest Box Breathing for this. Breathe in for 4 seconds, hold for 4 seconds, out for 4 seconds, hold for 4 seconds, and repeat. This will help calm any anxiety you may have about the uncomfortable floating or vertigo feelings, and will help you get to sleep at night. 

Tips to prevent eye strain & dizziness at the computer?

Dizziness, nausea, and eye strain while using the computer is very common. There are a few solutions, however it is one of the most irritating and long lasting issues I find my patients have. Eye strain occurs when our eyes become fatigued or tired from too much use, not enough blinking, and overexposure to bright lights. The other issue I most often see is difficulty scrolling; this is a separate issue usually ceased by over stimulus to optic flow, commonly called visual vertigo. Eye strain and visual vertigo can occur at the same time, but are treated differently.

Here are some tips for decreasing eye strain:

  • Use blue-light blocking glasses, your prescription glasses, readers, or migraine glasses always when you are at the computer. This will help your eyes not have to work as hard. 
  • Dim the screen light, or turn on night shift mode. This will decrease ether amount of blue light being emitted from your screen.
  • Use the 10m:10s rule. At least every 10 minutes, look up and stare at a non-screen and non-irritating focal point for at least 10 seconds. More than 10 seconds is useful, but it’s easier to remember 10m:10s! You can set a timer to help remind you to do this if you’re a person who gets “in the zone” at work.

Here are some tips to help irritation when scrolling:

As always, my best advice for eye strain and irritation on the computer is to perform Vestibular Rehabilitation Therapy. Your vestibular Therapist will be able to help you with optokinetic exercises. Optokinetic exercises are targeted at decreasing visual dependence, and helping your vestibular system work in a smarter way. If you are visually dependent, your eyes are working double time to do the job of your vestibular system when it’s having a hard time keeping up. 

Optokinetic exercises aim to increase your tolerance to optic flow, which is the concept of stimulus passing over your eye. For you, this may be irritating because your eyes are saying “we are moving” but your body’s proprioception system is saying “nope, we are not moving” and that mismatch is supposed to be distinguished by your vestibular system. However in this case, your vestibular system, which works like es switchboard operator, is not working like it should and cannot make the distinction between if you are moving or not – this causes dizziness. 

When your visual system is being over relied upon and you are under utilizing your vestibular system visual dependence is frequently the problem. Vestibular Rehabilitation Therapy and optokinetic exercises will help to solve this problem!

Where to find Dr. Madison Oak:

Website: Thevertigodoctor.com

Instagram: @thevertigodoctor

Email: madison@thevertigodoctor.com 

Hilton, D. B. (2021, January 8). Migraine-Associated Vertigo. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK507859/. 

VEDA. (2021, May 26). Vestibular Migraine. VeDA. https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/vestibular-migraine/.

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