TRANSCRIPT

Molly O’Brien: Hello, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. We know that the migraine brain can be hyper-excitable and extra sensitive to different stimuli. Our nervous system can overreact. That can trigger an attack, and/or we can feel extra sensitive during an attack or between attacks. So, is that just how it is, or is there something we can do about it? Science shows that there are benefits to regulating and retraining the nervous system. But what does that mean, how does it work, what does it look like, where do you even start? To answer these questions and more, I’d like to introduce our guest, Dr. Emily Kostelnik. Dr. Emily is a clinical health psychologist with specialized expertise in vestibular and related disorders. She brings both professional knowledge and personal experience to her work, living with multiple vestibular diagnoses herself. She is the founder of Rooted Behavioral Education and The Vestibular Psychologist. Dr. Emily, thanks so much for joining us today.

Dr. Emily Kostelnik: Thank you so much for having me.

O’Brien: So, we’re going to talk a little bit about dizziness, other types of vestibular symptoms and disorders, along with migraines. We want to make sure that this conversation is all inclusive for our friends out there. Let’s set up the conversation and really help people remember what the nervous system is.

Kostelnik: The nervous system is related to everything else in the body. So we’re going to be honing in on the nervous system specifically, but we’re going to walk through how it’s related maybe to the immune system, the endocrine system, all of that. So I just want to make it clear, these things don’t exist in isolation. There’s even a whole field of study called psychoneuroimmunoendocrinology.

O’Brien: That’s cool. 

Kostelnik: It’s a mouthful. With that said, so the nervous system is the central nervous system and the peripheral nervous system. And we’ll dive into the peripheral has like multiple branches underneath. The central nervous system is the brain and spinal cord. So a lot of times people think migraine lives in the brain. True, but it’s also very much a whole body experience. So the brain and spinal cord are really the command centers, they’re interpreting sensory input, they’re issuing instructions via neurons. So that’s central. Peripheral, we have three branches. We have somatic, enteric, and autonomic. We are going to be focusing on autonomic, but I’ll just overview what those are. 

So, somatic is voluntary skeletal and muscle movements. Enteric is the GI system, important for the gut-brain axis, but we’re not going to be diving too much into that today. And then autonomic is involuntary control, so things like heartbeat. From the autonomic we have two more branches, so think of it like a little tree. We have the sympathetic, that fight-or-flight, and the parasympathetic – rest, digest. People usually associate parasympathetic with the vagus nerve. The vagus nerve connects from the brainstem to the bodily organs, and it transmits sensory information from the organs to the brain and back down to the organs. So it’s kind of like a bidirectional highway. So does that make sense?

O’Brien: Love it. Thank you for painting that picture and breaking it down. And love thinking about the highway, it’s a two-way highway.

Kostelnik: There you go.

O’Brien: So, now that we have a refresher of anatomy, and we understand what these systems are and that they are connected. Nothing works in isolation.

Kostelnik: Right.

O’Brien: Can you help us understand the connection between our nervous system and migraine or migraine-like symptoms?

Kostelnik: Yes. So I’ll touch briefly on the central, and then we’re going to move into the peripheral and specifically autonomic. So, central is what we think about where research talks about the hyperexcitability, the neurotransmitters, inflammatory chemicals. Here is also where our emotion center lives and our thoughts, also very important. So our thoughts and beliefs, it’s again, always communicating with our bodies. But from there we’re going to move into the autonomic. That’s the classic what people think of as nervous system regulation. Usually, the body is giving hints that something is awry for months, maybe years, prior to the onset of migraine. And we’re going to talk more specifically. You mentioned vestibular migraine, vestibular disorders in general. 

So, typically what happens is someone experiences their first episode of dizziness or vertigo. A lot of times it comes out of the blue and it feels totally random, totally unpredictable, and people understandably react with panic, with a fight-or-flight. That sympathetic nervous system goes through the roof. We feel unsafe in our bodies, it feels very out of control, and then that’s like a trauma that gets stored in the body. It’s a survival mechanism. And then later on we want to remember things that are dangerous so we can tag them again in the future as something that was dangerous. So usually with the first dizziness or vertigo episode, it’s pretty traumatic for people. It gets stored and we’re like, whoa, that was dangerous, so I need to look out for that in the future. 

So, from there we tend to develop narratives. So again, there’s the central kind of thoughts, emotion-centered limbic. We develop narratives about what that means. So I’m dying, I might have a brain tumor. How do I deal with this, how do I problem-solve this? And we tend to try to cognitively problem-solve our way out of bodily sensations, which doesn’t work so well. So we tend to engage in rumination, rumination meaning thinking the same thing over and over, catastrophizing – what’s going to happen in the future, what about my identity? And this tends not to work so well for people. We then tend to start avoiding things, including bodily movement. 

So even like so many people I work with have slept on three, four, five pillows for years because if I lie flat I’m going to get vertigo. If I turn my head one way or the other the symptoms are going to come on. So we tend to avoid bodily movements, we tend to avoid engaging in life. That could be driving, it could be going out walking, it could be leaving the house. And what happens is our worlds become smaller and smaller and smaller. So we then develop this faulty association – because I avoided this thing, I didn’t experience symptoms. So this is called reinforcement, it’s called negative reinforcement. So because I avoided something bad, I’m going to be more likely to do that behavior again in the future, and then that maintains this vicious cycle from the central autonomic connection. 

Our bodies are always listening to our thoughts. So when we’re telling ourselves either consciously or subconsciously this is dangerous, this is out of control, I can’t handle this, this maintains that fight-or-flight, the chronic fight-or-flight. That then has a trickle-down effect. Our stress hormones get dysregulated. So when we’re in this constant state of fight-or-flight, cortisol and adrenaline is pumping through our bodies all the time. Our bodies also preference stress hormones over sex hormones, because stress hormones – fight-or-flight, survival – versus reproductive may be on the back burner if we think that our life is threatened. 

So when the stress hormone system gets really dysregulated, that has a trickle-down effect to the immune system. We develop chronic inflammation, which then has a feedback loop into the rumination nervous system cycle. The latest target of research for anxiety and depression is on the inflammatory component. So it makes it harder to get out of that rumination and fear cycle when you’re in inflammation, but you can see that the cycle kind of maintains itself. And so when figuring out how to calm the nervous system, where is an entry point, how do we break this cycle? And that’s what we’re going to talk about here. 

One other thing I have to mention, because it’s very kind of foundational to all of this, is something called central sensitization, which I know is talked a lot about in the migraine community. A lot of people associate it specifically with pain, and that is true. It also applies to dizziness. So you’ll see that less in the literature, but it applies to both things. So, it’s essentially when the brain and spinal cord become hypersensitive to everything, because we’ve learned to tag everything as a threat. And so when our world becomes smaller and smaller and smaller, we’re not exposed to things. Maybe we’re wearing sunglasses inside, maybe we’re wearing earplugs. Maybe we have only unscented products which is not bad, but then you go to the grocery store, and you walk down the detergent aisle and you’re like, oh my gosh, danger. So, when our world gets smaller and smaller and smaller, our nervous systems learn to react to smaller and smaller and smaller stimuli, which is why then people can develop sensitivities to literally anything and everything. So light, sound, food, supplements, barometric pressure, stress, or sleep, all of these things. 

So it’s a survival mechanism for the body to feel safe, but we can see how that is not so helpful. It might work in certain situations, but then on a chronic basis it doesn’t work so well. And then that is also related to inflammation, because our immune like gate guards if you want to put it that way are called mast cells, or these white cells in the immune system. When they perceive danger, they release inflammatory chemicals, including histamine. And I know histamine is something that is talked about pretty frequently in the migraine community. So it’s this vicious cycle of nervous system-immune system-endocrine system that becomes dysfunctional, and we have to figure out how can we pedal backwards to undo that vicious cycle. Central sensitization is also why many people develop other comorbidities, so things like chronic fatigue, fibromyalgia, IBS. Those are common ones that I see, but there are others. So, does that make sense, any questions on that one?

O’Brien: Oh, so many. But, okay. So I guess my first thought is it’s all so fascinating how everything is so interconnected, but it also makes sense. As soon as you started talking about the dizziness and going to that fight-or-flight mode, I had an emotional reaction to it. So I immediately thought, yes, I can remember that time where I had my baby upstairs and needed to get downstairs, but I couldn’t go down the stairs. It’s that thinking of, oh, no, now what? And then you get the ruminating.

Kostelnik: I think the emotional response can come from just feeling validated, because I’ve seen providers that I don’t know what this is, it’s in your head, whatever. So even just putting a name on something and saying this makes sense can make people feel very heard. And the pain versus dizziness. I don’t want to say vestibular migraine is worse than classic migraine or anything like that, but there’s something about dizziness that shakes the foundation of who you are. That’s different than pain. With pain, a lot of times people can still drive, or walk, or engage in the things that they need to do, albeit with a lot of discomfort. But with dizziness, it’s like I can’t even move around in the world.

O’Brien: We’re not comparing, or contrasting, or measuring different symptoms and that kind of thing, but I think it’s important to acknowledge that. How do we know if we have a dysregulated nervous system, is it those extra sensitivities? What does it look like, what does it feel like?

Kostelnik: So, I would say anyone who’s dealing with dizziness on an ongoing, chronic basis likely has some level of nervous system dysregulation because it’s kind of normal. If you’re experiencing these symptoms all the time, it feels dangerous really. So if you’re in fight-or-flight, it typically feels like restlessness, irritability, agitation, insomnia, hypervigilance – hypervigilance meaning scanning your body for danger, scanning your environment for danger – difficulty relaxing, heart racing, ruminating, sweating, dizziness, increased blood pressure. So that’s symptom-based, but how that actually looks in real life? Constantly Googling, checking Facebook groups for reassurance over and over again, scrolling on social media, not being able to sit still or pay attention to a show even. So the barometer for me of is my nervous system dysregulated right now? If I’m sitting in the car and I’m going through radio stations, and there’s songs that I like but I’m like, oh, I don’t want to listen to this, nope, I can’t get into it. It’s like just this discontent. It’s this restlessness, this I can’t settle in and enjoy something, if that makes sense. So that’s more of the fight-or-flight piece of it. 

There’s also the shutdown piece, which I know we didn’t talk as much about, which might look a little bit more depressive. So that might be more like low energy, slowed heart rate, low blood pressure, constipation, depersonalization, derealization, feeling numb, hopeless, helpless. How that looks in practice? Generally feeling overwhelmed, like I don’t even know how to take one step forward. You might feel like you’re slowed down, like you’re walking through molasses. You might feel like your brain has no energy. And the shutdown is actually a sympathetic state, which I know is kind of confusing. So we have sympathetic which is that fight-or-flight. Parasympathetic is usually where we want to be, but there can be an over parasympathetic shutdown type system. So I hope that makes sense.

O’Brien: Yes. And my follow-up question is can we have both at the same time? We’re in that fight-or-flight, we’re not getting comfortable, we feel agitated, on edge, but also at the same time it’s difficult to do anything. It’s difficult to maneuver, we’re exhausted. Is it possible for those to coexist?

Kostelnik: Yeah. I think that a lot of the things that we talk about are kind of theoretical based on this researcher’s idea or this researcher’s idea. So as it stands now, we’ll call them anxiety and depression. I don’t even like those terms, I feel like they’re stigmatized, and I’d rather just describe what it actually is. But the truth is we don’t know. “Anxiety and depression” (we’ll put that in quotes), are those actually separate things? I would say probably not. Another theory that comes to my head is Steven Porges’ polyvagal ladder. So at the top is ventral vagal, that’s like we’re open to socialization, we’re open to new experiences, we’re content, we’re reacting flexibly to stress. Below that is that fight-or-flight sympathetic. Below that is dorsal vagal shutdown. So he argues we can go through the different stages at different points. So yes, they can coexist. Throughout the day you might be going up and down the ladder, or you might be stuck in one spot, or you might have some overlap between the two. So, I would say in my clinical experience, yes, you can have overlap between those different things.

O’Brien: What does it mean to get it all back in check? What does it mean to actually regulate your nervous system? Before we get into how, let’s talk about what that even means.

Kostelnik: It’s not glamorous. It’s not the device or the super advanced thing. I will say most everyone who comes to me, myself included, so I will say us tends to be type A – perfectionist, overachieving, people-pleasing, self-sacrificing, trouble with boundaries. So, we really have to change the way that we interact with the world. I know a lot of people want to hold on to tools, and they want to do things. And I think doing can be part of the problem, we’re doing a lot of doing and not a lot of being. So we need to slow down. We need to do one thing at a time and not multitask, we need to be in the moment, we need to savor gratitude and joy. So how we’re interacting with the world, we teach our brain what’s important. 

So where I’m putting my attention is teaching my brain how to create those new neural networks. So when I’m on Google for hours on end looking up dizziness, whatever – do I have a brain tumor, do I have this, am I going to be ever be able to drive again? You’re teaching your brain those symptoms are super important, and this fight-or-flight state is how I want to stay. So figuring out how to pan away from that and focusing on what we want to rewire cords. So I know there’s a lot of talk about neuroplasticity. To create neural networks, we have to be replacing the old ones with something, if that makes sense. And another really important thing is figuring out what’s important to us, because a lot of people chase happiness, or joy, or these specific kind of fleeting emotions. And it’s more about what’s important to us, what makes us feel fulfilled, what gives us purpose. And so that’s a big values discussion, and it’s something that I talk with all of my patients about. 

So regulating the nervous system, it doesn’t mean being calm all the time. It means that we can react flexibly to stress, and that we don’t get stuck in this state. Because there’s a reason we have cortisol and adrenaline and these different things, they’re helpful in some instances. Sometimes “anxiety” (we’ll put it in quotes) is adaptive. So you know when your nervous system is regulated when you are not constantly looking up symptoms, you’re not in the Facebook groups, you feel like you can relax and enjoy a TV show or enjoy a song. You might fall asleep more easily, you might wake up feeling more rested. You might be able to be in the moment more, you might not be ruminating as much, you might not be thinking about the future or worrying about the past. You might be more open to trying new things or socialization. And I know a lot of this feels kind of nebulous, abstract. I know we talked about how all of this stuff is related. It really is very physiological. So I want to emphasize that, too, because I think nervous system stuff can get thrown by the wayside a little bit.

O’Brien: I want to go back to how you started answering that question with including us. And I think everything that you described –being driven, trying to find success, trying to find happiness, multitasking, all these things. It feels like as a millennial woman that’s what all of my peers have been doing, that’s how we were taught to function almost. And so breaking away from these things that we think we’re supposed to be doing all the time – we’re supposed to be moving, we’re supposed to be busy, our plates are supposed to be full all the time – that’s really hard to break out of. I have to say personally I’ve done a lot of work to try to break out of that cycle and to realign my brain on what is happiness, what is success, how do you measure that, does it matter that you’re measuring it? So it feels almost like we’ve been put into this. But we can get out of it. So I wanted to say that, because I deeply recognized every single thing that you said.

Kostelnik: Same, same. I’m right there with you.

O’Brien: You gave specific examples of can I sit and listen to enjoy a song, can I sit and watch a show and enjoy it? Those are some signs that maybe my nervous system is dysregulated. We all love tools, and we all love things we can do, and we all love to fix it. So let’s talk about some things that we can actually do.

Kostelnik: Yeah.

O’Brien: What are some therapies, what are some techniques? How can we go about getting our nervous system regulated? And with that, is it an in the moment thing, is it a long-term thing?

Kostelnik: I would say it’s a lifestyle change rather than something to jump in and jump back out of, because of the way that the brain works. So we have these neural networks. Maybe we have our dizzy networks, that’s like dizziness equals anxiety, and those things are always paired together, and we want to kind of break off and do something different. These neural networks don’t go away. So if we don’t maintain this lifestyle change, we’ll default back to the way that we were. 

So I’ll talk about my favorite techniques that I’ve seen work in clinical practice, which are acceptance and commitment therapy, or ACT thematic techniques. I’ve gotten a lot more visualization, something called Internal Family Systems or parts work, and I’m going to unpack all of this. Also, EFT (Emotional Freedom Technique) tapping. You’ll see CBT is not in here. There might be people that disagree. CBT and ACT are the things with the most research support within this community. CBT has over 80,000 publications not for vestibular disorders but just in general, it’s the most studied therapy. But it’s not my favorite for this population. I find mindfulness-based practices work better. And something that CBT is missing is the somatic part of it. So I talked about how we constantly are trying to cognitively problem-solve our symptoms, which doesn’t work very well. CBT lives up here, and we have to learn how to become safe in our bodies or there’s always going to be a disconnect. 

I will say with tools, they’re, like I said, a lifestyle change. They have to be practiced with a lot of repetition. They’re not something to be used just in the moment when you’re panicked and you’re having a vertigo attack, because you need to build that neural network. You need to build the muscle memory, depending on what exactly it is that we’re doing, so that your body doesn’t associate the tool with the negative experience. One thing that is really important to say. People approach these tools with the same urgency and perfectionism that got them in this place in the first place. So I want to make that very clear. There’s no perfect, there’s no I did this wrong, there’s no shame that needs to be associated with this. So that is really important as well. So with all of that said.

O’Brien: Again, I got emotional because I can picture myself being like, oops, I skipped my exercise today. I skipped this, I didn’t do it right, I’m not seeing results immediately. So thank you for framing that. Okay, now I’ll let you get into it.

Kostelnik: So ACT can be a little confusing. I’ll try to break it down to make it as concrete as possible. But the idea is human suffering is based in language. So we have this idea of pain versus suffering. So pain is a normal part of the human experience, everyone’s going to experience it in some form or another. So maybe for those of us with a vestibular disorder, that’s dizziness and vertigo and imbalance. Suffering is the language we add to the pain, so the beliefs we have about it, the expectations we have, the narrative – this is what my future is going to look like. So it takes something that’s painful, and it takes it from like this size to like this size. So the goal with ACT is to take that suffering piece away and have more psychological flexibility around the way that we’re interacting with the world, and the way that we relate to our bodily sensations. 

And it’s very values driven. So it’s very much like figuring out what’s important to you, and how do we make decisions around living in service of those things. So whereas with CBT you’re constantly in a back and forth with your thoughts, in ACT it’s about changing your relationship with your thoughts. So rather than looking at the world from your thoughts, believing all of your thoughts to be true, you’re able to step out of that and look at your thoughts with more curiosity, if that makes sense. 

So one quick tip from ACT is beginning to recognize when I’m down sort of like a rabbit hole of unhelpful thinking – again, no shame involved, no judgment, it’s just like a, oh, there I am again, I’m thinking this thing. Cutting that off and coming back into the moment with our five senses. So the first step in moving away from this dizzy pathway, if we want to call it that, into the valued pathway is stopping it when it starts and veering into a different direction, if that makes sense. 

O’Brien: Okay, yeah. 

Kostelnik: So ACT has a lot of different tools and stuff, but that is one of the most foundational is interrupting those thoughts and coming back into your body. So I’ll move down to somatics. So this is about befriending the body, changing the way we experience bodily sensations. This could be things like breath work, body scans, orienting to our environment. Different techniques like trauma release exercise like shaking, and various things to kind of diffuse energy. They all have to be taken with care with trauma, but somatics specifically with the history of trauma. People have a very hard time being in their bodies because their bodies are not safe. I’m just thinking about a client that I’ve worked with. Any level of putting attention on the body, immediate panic symptoms. So that has to be taken very, very slowly, and with someone who is experienced. 

Visualizations, hugely helpful. I’m doing those more and more with myself and with the people I work with. So our bodies don’t know what’s real versus what’s imagined. So that’s why when you’re imagining yourself disabled and not being able to be a mom, or not being able to drive, your body reacts as if that’s actually happening, it’s pumping that stress chemistry. So we can flip that on its head and visualize things we want, things we value to cultivate that I don’t want to call it happy chemistry, because I know we’re not chasing happiness, but the dopamine, serotonin, oxytocin, endorphins. So positive visualizations can be very, very helpful. 

Another one of my favorites is EFT tapping, Emotional Freedom Technique. It’s an acupressure. You do different acupressure points to help calm the nervous system. I’m getting more and more into something called Internal Family Systems or parts work. It’s similar to ACT, but rather than separating from thoughts, it’s more like identifying different parts of ourselves. So I might have a protector part, or a critic part, or a judge, or the perfectionist part, and being able to gain some space from that and see it as a neural network on repeat and engage with it in a different way, if that makes sense. So that’s sort of a high-level description.

O’Brien: Because we have the folks out there who are like, well, give me a tool, give me something. What does that look like, what does the practice look like? Obviously, everybody’s going to be different, and we’re going to talk about when it’s time to seek out a professional to get help.

Kostelnik: So I think if I had to give a universally helpful few techniques that wouldn’t require someone to understand your trauma history and make sure you’re not going to flood yourself, or make things worse for you, I would say that thought interruption that I mentioned of interrupt thoughts, come back to five senses. So what that looks like. So let’s say I’m standing and cooking breakfast. I’m in catastrophic [thinking], like I’m not going to be able to work my job, etc., whatever those thoughts look like. I’m going to be like, oh, stop, cancel, I’m doing that again. I’m going to come back to my five senses. So I’m going to feel my feet on the ground, I’m going to smell the food that I’m cooking, I’m going to hear the sizzling of the pot, I’m going to taste something. So that’s an example of engaging in the moment, because typically in the moment we can find something that’s safe. Like this food in front of me is safe, or I might orient and look at something beautiful and describe it in my head. Because a lot of times we’re like on autopilot tunnel vision. So that canceling the thought, coming back to the body. 

I would say orienting can be pretty safe, too. So a lot of times when we’re in that tunnel vision, we’re not moving our heads around. So even looking around and finding something safe in the environment. So like, I see a tree outside of my window. I might try to notice things on the tree that I never noticed before. Or this little truck that my son left here. It’s like, oh, that makes me think of him, which I would never notice that if I was just sitting here zoomed in completely on you. So interrupting thoughts, orienting to your environment. 

The other thing that I would say is relatively universally safe is breath work. And a lot of people think, breathing, I do that, how could that possibly be helpful? It’s universally one of the most helpful things that my clients report. So that might look like diaphragmatic breathing, it might look like physiological sigh. So breathing in, pause, breathing in again, big sigh out. It might look like VOO breathing. So breathing in, breathing out and say VOO, VOO to activate the vagus nerve with that kind of humming. 

So I would say those are the universally safe ones. I don’t want people to feel afraid of nervous system techniques, but getting into the body can require some care. You don’t want to flood people’s system, you want to help build capacity of their nervous system. There’s a term called the window of tolerance that was coined by a psychiatrist around the nervous system. So with that central sensitization and fight-or-flight, our window of tolerance becomes very small, meaning a lot of things cause us to flare, essentially. So we want to work on widening that window, building that capacity in our nervous system to be able to dive in. 

I’ll give an example of why you shouldn’t do things you see on TikTok. I saw someone say you should do this journaling prompt, and journal about something that’s happened to you in the past, for example. If someone goes and does that, and they don’t have the capacity, they don’t have a trained person – because there’s something about being in a therapist’s presence, or even a trusted person that helps you co-regulate, so it’s like a safe container. So if you go and do this exercise and it floods you with thoughts, and emotions, and nervous system experience from the trauma, you don’t have anyone there to help you co-regulate, it can send you into a spiral.

O’Brien: If people are interested in getting their nervous system regulated, when might it be time to look for some help, to get into these techniques so you’re not just at home scrolling and trying things that could be making it worse? When might someone know that it’s time to seek some help? And also, what do people look for, or how do we know if someone can help them? One, so that they’re finding a safe resource and healthy resource, and two, they’re finding someone that can actually help them, and not just someone on the internet.

Kostelnik: I’m a big fan of anyone and everyone, you don’t have to have a diagnosis of anxiety, or depression, or whatever. But I would say if you could recognize with some of those things we listed, if you feel like your nervous system is preventing you from moving forward, if other treatments aren’t helping, if you can’t tolerate any of the treatments, that is a big red flag that that’s nervous system related. If you have a history of trauma. Even if you know the techniques, but you are having trouble implementing them and you need an accountability partner. All of those would be good reasons. As for what to look for, I think the best parallel for dizziness tends to be chronic pain. And there are many, many more mental health providers trained in chronic pain. For example, in the VA system they have chronic pain clinics, and as we go through graduate school a lot of people do training through that. So I would say someone who specializes in chronic pain will have a pretty decent idea of the nervous system regulation tools that you would need.

O’Brien: Okay. And could regular therapy help, and then you work with a counselor or a therapist? Or should we look for someone who has experience in chronic pain? Like where can people start? Can you go on Psychology Today? Or who are we looking for, where can we look for this?

Kostelnik: I wish I had a surefire this is exactly someone. I’m a big fan of ACT because of the mindfulness-based piece. So there’s a website called contextualscience.org, those are ACT-based providers. You can go on Psychology Today and filter based on specialty, and insurance, and location, and virtual versus in-person, so there is a way to do that as well. From there – I hate to say this – so much of it is based on personality fit. We know based on the research, above and beyond the tools that we’re using, the therapeutic relationship accounts for the most amount of change in therapy. So one thing I find that I think the chronic pain maybe would be good for. A lot of people come to me having tried other therapists, and they feel exhausted, of course, explaining all of what vestibular means. But sometimes, I don’t want to say a tough love approach, but an education approach. 

Sometimes people can end up with a therapist who’s almost over-validating and makes people feel stuck. Sometimes therapists don’t know the prognosis or how much you can get back, if that makes sense. And I’ve even fallen prey to that with my own therapist in the past of over-validation, and then me taking a step back and be like, no, this isn’t how my life is going to be forever, I can make so much more progress, I know all of these things. And so I think finding a right personality fit of someone who you feel safe and validated by, but also you feel is a good accountability partner and can help propel you forward, if that makes sense.

O’Brien: Absolutely. And it’s hard to do, it’s hard to find someone. But there is hope and there are options out there for us. So, Dr. Emily, as we wrap up here, I could talk to you all day. Can you talk to us what healing looks like, what expectation should be, what does it mean to get our nervous system back into this regulated state?

Kostelnik: From a behavioral perspective, I’ll say that and then kind of outcome perspective. Behavioral perspective is, I don’t want to say you feel like a different person but radically changing the way that you engage with your environment. So learning to say no and be okay with that. Setting boundaries, Again, being able to engage with your family. And that’s not to say you have to be symptom-free because those things can coexist. Remember, from an ACT perspective, we can have the pain without the suffering. So I would say it’s figuring out, maybe making accommodations, but still doing the things that are important to you and feeling fulfilled, feeling like you’re able to flexibly handle stress as it comes your way and you don’t completely melt into a puddle. You’re not seeking reassurance all the time, you’re not continuing to look – are you sure I have vestibular migraine, I don’t think that’s my accurate diagnosis. So coming to a place of acceptance of this is how it is in this moment and that’s okay. And I can continue to take steps towards improving my situation but not putting life on hold because of the sensations you’re having in your body.

O’Brien: In a safe way for our overall audience. If someone has five minutes a day to try to get their nervous system regulated, what’s one technique?

Kostelnik: So if I had to pick one thing – and we know why maybe having only five minutes a day for yourself is problematic. If someone came to me like this, I would work with how do we create more space for you. I have a client who’s exactly in this situation, working multiple jobs, and grad school, all of these things. And I’m like we need to create more space, because our nervous systems are not meant to exist like this. So with that said, aside from creating more space, I would say breathing would be at the top of my list. So that would be if you had five minutes a day. Beyond that, I would say try to slow down in your day by like 20% and see how that changes things. So it’s more about what you do for the duration of all day every day, rather than the one tool that you’re using. But because you’re asking for one tool, I would say breathwork would be at the top of my list.

O’Brien: We really appreciate your expertise. This conversation has been fascinating, I think so informative, educational. It’s really going to resonate with a lot of people. I think a lot of people’s light bulbs are going to turn on, I hope. 

Kostelnik: I hope so too. 

O’Brien: I really do. Is there anything else that you want to share, last final thoughts?

Kostelnik: Yeah. I think my final thoughts are that you know your body best, don’t let anyone challenge that. And if you’re feeling like I’ve tried everything, I don’t know what else to do, I promise you have not tried everything. That’s my whole mission of all of my business and my professional stuff is always to be looking at the cutting edge and pushing the envelope and figuring out other things we can do. It’s not just the standard migraine medications, or the standard migraine supplements, or CBT, there are so many more things. And so I want you to always have hope that there are always things that you haven’t tried.

O’Brien: Dr. Emily, thank you so much for joining us today on Spotlight on Migraine, it’s been an absolute pleasure.

Kostelnik: Thanks for having me.

O’Brien: If you want to learn more about nervous system regulation, dizziness, and other things, you can follow Dr. Emily on her social. Her Instagram is Dr. Emily Kostelnik. Or you can check out her websites, Rooted Behavioral Education and The Vestibular Psychologist. Links are in the transcript. To all of our followers out there, thank you so much for listening. Don’t forget to hit like and subscribe. This podcast is made possible by supporters like you. You can make a tax-deductible donation today at migrainedisorders.org. And that wraps up this episode of Spotlight on Migraine. I’m Molly O’Brien. We’ll see you next time.