Dizziness, vertigo, and feeling off balance can be some of the most disabling symptoms of vestibular migraine, but is vestibular therapy the right solution?

In this episode of Spotlight on Migraine, host Molly O’Brien sits down with physical therapist Madison Oak, PT, DPT (aka The Vertigo Doctor) to break down what vestibular rehabilitation therapy actually is, who it was designed for, and how it may fit into treating vestibular migraine. Oak also shares insights from both research and clinical experience, what progress looks like, and why vestibular therapy can be helpful for some people, if the timing is right.

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TRANSCRIPT

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Molly O’Brien: Living with dizziness, spinning, feeling lightheaded or off kilter, these symptoms can be really disabling. Vestibular therapy may be recommended for people dealing with dizziness or balance problems, but when migraine gets involved, it’s a little bit more complicated. Hi, I’m Molly O’Brien, and welcome to Spotlight on Migraine.

In this episode, we’re looking at vestibular rehab. So what is vestibular rehabilitation therapy? Who might it help, and why might timing and overall migraine management be the keys to making it work? To help us break this all down, I’d like to introduce our guest, Dr. Madison Oak. You might know her better as the Vertigo Doctor on Instagram.

Dr. Oak is a physical therapist specializing in vestibular migraine and other vestibular disorders. She’s the driving force behind Vestibular Group Fit and Oak Physical Therapy and Wellness. Madison launched the Vertigo Doctor on Instagram and established a telehealth clinic serving seven states exclusively for vestibular disorders and introduced Vestibular Group Fit after realizing there was a giant gap in information about dizziness and treatment.

These initiatives collectively offer evidence-based, cost-effective resources to people living with vestibular disorders. Dr. Oak, thanks so much for being with us today. It’s great to have you back on the podcast.

 

Madison Oak, DPT, CCVR: Thank you so much for having me. This is truly my favorite topic, so I’m really excited to talk about it.

 

O’Brien: We had a great conversation last time we talked to you all about the vestibular system, about different vestibular disorders, so we’ll do a little bit of recap but highly encourage our audience to go back and watch that last episode that we did, link in the transcript, but we appreciate your time and so happy to have you back. And let’s just dive into it. First off, since this is your favorite topic, what is vestibular therapy?

 

Oak: So vestibular therapy is a type of therapy for your peripheral vestibular system, and it is my first love because I love having people feel better from being able to shake their heads around. So vestibular therapy is any therapy for the vestibular system itself. It is a peripheral system. There are two types of vestibular disorders. You can put them in two buckets. 

There’s the central vestibular disorders. Those are your vestibular migraine, PPPD, concussion, things like that, things that live in your brain. Stroke can sometimes be a central vestibular disorder. Then there’s the peripheral ones, the ones that are actually affecting the vestibular system itself. So think Meniere’s disease, vestibular neuritis, vestibular hypofunction. Now, obviously here we’re talking about migraine. We’re going to talk about central vestibular disorders and how vestibular therapy can be helpful for those.

But vestibular therapy ultimately, like the therapy itself was designed for those peripheral vestibular disorders. So VOR times one, shaking your head around, staring at a spot, balancing with your eyes closed on a foam pad is something people do. Moving your whole head and body while staring at your thumbs, VOR cancellation.

So those types of exercises are designed to help pair your vestibular system with your brain again. And the vestibular system, we talked about this last time, quick recap, works like a cable television or the cable box is your vestibular system. The wire to your TV is your vestibulocochlear nerve connecting your vestibular system to your brain. And your TV is your brain where its job is to make sense of all of that information. Peripheral vestibular disorder affects the cable box. Central vestibular disorder affects the TV.

 

O’Brien: Before we get too caught up in talking about vestibular therapy, you were saying that vestibular therapy was designed for the peripheral category. 

 

Oak: Correct. 

 

O’Brien: Vestibular migraine lives over here because it affects the brain. But we might see some benefits – we’re going to talk about that – even though it totally wasn’t designed for that at all.

 

Oak: Ultimately, I say that because those are the diagnoses we knew of when it got invented. 

 

O’Brien: Fair. 

 

Oak: But then all dizziness conditions get put in a similar bucket. Your medical doctor sees dizziness. They think, oh, I learned in school to send these people to vestibular rehab to shake their heads around. That’s what’s going to make you feel better. This is no one’s fault that sometimes it goes haywire. It’s not your fault. It’s not your doctor’s fault really. Yes, they should do more research, but that’s just not what is taught in school. The information that I have is truly from seeing what happens clinically to people.

 

O’Brien: Because people have vestibular symptoms like dizziness, lightheadedness, all these different symptoms, and they can be caused by various reasons. They could be affecting that TV, like you said, the brain, or they could be affecting the wire, the vestibular system. Let’s talk a little bit about how we might be able to differentiate and understand where these symptoms are coming from, and then can they overlap?

 

Oak: They’re not mutually exclusive from each other, which makes it difficult sometimes to diagnose what this actually could be. But a lot of people do have multiple. It can be difficult to determine which one it is.

Honestly, the best way to go about figuring out which one you have is a really good clinical history, but that requires a really good clinician to know what they’re looking for. For example, Meniere’s disease and timing can be the thing that differentiates them. Meniere’s disease, a peripheral vestibular disorder, requires 20 minutes to 12 hours of room-spinning vertigo, meaning you don’t feel like you’re spinning.

You see the room spinning for hours at a time, paired with hearing loss and roaring tinnitus. But the hearing loss needs to be in the lower frequencies, not just across the board “normal hearing loss with age.” But sometimes it doesn’t stay after the attack, so you’d have to have a hearing test at first during an attack until it becomes progressive. So that’s Meniere’s disease. But that being said, room-spinning vertigo like that, that last hours and hours, can also come from vestibular neuritis. It can also come from vestibular migraines.

Then you have to differentiate, did this happen one time in my life? Because if it happened only one time, it’s more likely vestibular neuritis. Then you’ll get a VNG afterwards, a video nystagmography exam with your audiologist, and that will show a loss on one side or the other of vestibular function. They put this like hot or cool air or water in your ears. And then that shows basically how much your eyes spin. Your eyes are supposed to spin in that situation.

People are like, I hate the spinning. I know you hate the spinning, but that is actually showing that your vestibular system is working, which is kind of cool. So you’ll get one of those tests and they’ll be like, oh, you have a history of neuritis.

This happened one time, maybe you were sick first, then the room spun for 24 to 72 hours. That’s horrible and uncomfortable. You probably were very ill for a couple of days. And then slowly it starts to get better. But for people with a history of migraine, that then triggers vestibular migraine for a lot of people. So now you have this history of neuritis, right? And you’re like, but it keeps happening. Like it keeps getting worse or it keeps changing, right? And I have this history of neuritis that shows on my VNG.

Let’s say like you immediately got it diagnosed, which is very rare, but let’s say for argument’s sake, you immediately got it diagnosed. You’re like, okay, I have this neuritis, but it keeps coming back. It’s usually the neuritis triggers it. Then you have migraine. And then now you have vestibular migraine because that nerve isn’t working as well. And so yes, you can totally and completely compensate for a neuritis.

But then if you have this chronic vestibular disorder of migraine, then the symptoms keep cropping up and flaring up. And again, this is where you need a really talented clinician to tell you what you’re dealing with. And once you know what to look for, it’s glaringly obvious.

Like I’m not a medical doctor and I’m honestly hardly wrong when I’m like, I can’t give you a diagnosis, but I’m like, hey, you have signs and symptoms consistent with these couple of things. I want you to bring this evidence with you to your doctor and put it this way and they can help you decide. Right. And sometimes I’m totally wrong. Like I am not a medical doctor. That is not my job to diagnose.

But oftentimes, because I’ve seen it so many times, I’m like, hey, I think this is what you might be dealing with. You have signs and symptoms consistent with neuritis, PPPD, migraine, let’s say, again, for the sake of this argument. And they’re always like, oh yeah, that is right. Not always, but very frequently. Because once you know what to look for, it is often glaringly obvious what you’re dealing with. So you want to know, do you have a peripheral disorder, central disorder, an acute situation, a chronic situation, or both, or some combination.

 

O’Brien: Let’s talk a little bit about vestibular therapy and who may be a good candidate for vestibular therapy, who may benefit the most.

 

Oak: Almost every person with any vestibular disorder should at some point in their journey go to vestibular rehab. But I’m going to throw in a huge caveat and say that you need to be ready for vestibular therapy. Now, what that actually means is that your brain wants to do neuroplasticity.

We can do negative neuroplasticity, which is the kind that makes things feel worse that we don’t typically want. And then positive neuroplasticity, aka less dizziness. Everyone can at some point in their journey with any vestibular disorder be a good candidate for vestibular therapy.

If you have BPPV acutely, you should immediately call your vestibular therapist and go get an Epley maneuver or Semont or Gufoni or whatever other crazy name we have for these maneuvers almost immediately because that is very treatable. Then we talk about the chronic vestibular disorders. Vestibular migraine and PPPD are made more complicated with vestibular therapy because migraine is not inherently only a vestibular disorder. It affects your mood. It affects anxiety and depression. It is affected by what you eat, how you’re sleeping, how hydrated you are, right?

Migraine is a bucket disorder, a threshold disorder. If you’re going to try and treat vestibular migraine as only a vestibular disorder, you’re not going to get very far because you’re now filling your bucket with more and more and more triggers. And we know not to just “avoid triggers.”

We want to build a bigger bucket, build a bigger threshold. So more triggers fit into that bucket before you go into an attack mode. The goal of vestibular treatment is to make you less dizzy by shaking your head or moving your body in certain ways, walking with head turns, balancing on foam things.

And while it will help with vestibular migraine sometimes, it’s not always. And the research shows, it says, hey, if you do these exercises, your migraine frequency will reduce. And the problem is that a lot of people drop out of those studies.

So the people who are made worse by it, they drop out. They don’t come back. So they’re no longer in the research, right? Now there’s a bias that way. And also a lot of them are retrospective. A lot of them don’t necessarily look at function.

So it’s really, it can be difficult because all of a sudden now maybe you can spin your head at 240 beats per minute like this, but you can’t drive still. You can’t walk down the street by yourself still because you’re still dealing with this migraine problem. Or you’re doing these exercises, you’re like, I’m so good at these exercises, but I’m having an attack every other day now. And some people don’t link together that that’s the problem. And also a lot of times the studies don’t account for people also having persistent postural perceptual dizziness, which is really, really common with vestibular migraine.

And that’s this like chronic background rocking and swaying that’s there all the time made worse by busy environments, worse when you move around. And also is attached to the dizzy, anxious, dizzy cycle gone wrong. At some point in your migraine journey, in your vestibular migraine journey, I should say, vestibular rehab could be really helpful.

And what I always say is you need to be “ready for it.” And what ready for it means, it doesn’t mean you never have an attack again. It doesn’t mean you haven’t had an attack in six months.

It means when you have an attack, you have something you can do about it. You have a neuromodulation device that works, a medication that works, a supplement electrolyte protein regimen that works, whatever you want to do to treat your migraine acutely. I don’t care what it is, but if it works for you, that’s a great first step.

Moving your head around, in general, throughout your day, doesn’t bother you so much. Like you can walk down the street or turn around in your kitchen and you’re like, yeah, I don’t love it. It’s a little bit irritating but doing just that isn’t throwing you into a whole attack.

My whole thing is that you can do anything you want to do from skydiving to walking around the block with a vestibular disorder. You just need the right tools to get there. And vestibular rehab might be a tool in that kit.

 

O’Brien: I want to backtrack a little bit to what you said about the research out there, how it could be a little bit flawed. It’s all about perspective. There was a recent study published in Headache showing that people with vestibular migraines saw “positive, meaningful improvements” after doing vestibular therapy. So can we talk a little bit more about that and then what you have seen in practice?

 

Oak: I do agree that it can be really helpful. I don’t want anyone out here thinking that I like hate on vestibular therapy. That being said, clinically, we don’t necessarily see that.

So in this study, I just pulled it up again. It says basically that we need more blinded, randomized controlled trial studies to help isolate the possible therapeutic effects of vestibular rehab and other general effects. So this review does say that, hey, this is something that we have found to be kind of helpful.

Previous studies validated that the use of vestibular rehab in the treatment of vestibular symptoms for patients with VM to include improved headache and migraine-related disabilities in patients with VM. But these studies don’t limit for or unbiased themselves for chronic dizziness, how frequently they’re having vestibular migraine, like chronic versus episodic. They’re not all doing that. And so…

 

O’Brien: You can’t factor everything.

 

Oak: We can’t factor every person in. If you have episodic vestibular migraine that happens sometimes and you have a medication for it, you are probably the perfect candidate for one of these studies. Because you’re like, I feel pretty good, but I have trouble unloading the dishwasher.

Because vestibular stimuli are so stimulating, if you can desensitize yourself to those in vestibular rehab, then also your migraine days will probably reduce because that broadens your bucket. 

 

O’Brien: That makes so much sense. 

 

Oak: It makes a ton of sense, but it also works. It does amazing things. I love vestibular rehab, and I have given my vestibular migraine patients vestibular rehabilitation exercises a lot. VRT can be helpful for VM. If it has gone poorly in the past, it doesn’t mean it will go poorly in the future. It just means you probably weren’t ready yet. And I have very kindly kicked people out of my clinic because I’m like, you are not prepared for this. This is not a good idea for you.

But if you’re like, I want to keep seeing you, we do completely other things that have nothing to do with shaking your head around, nothing to do with balance, all to do with, okay, how are you sleeping? How are you eating? And the amazing thing about physical therapists, we also are really pretty good at all the other lifestyle factors also.

Clinically, what I see be the most helpful is shifting your mindset. Remember, we have some level of mindset kind of emotional support help that PTs can do. Moving your body in a way that’s comfortable for you. Starting with two or three minutes a day, be really gentle with yourself at first, and then working your way up. More strength, more cardio. You don’t have to like do a HIIT workout and sprint on the treadmill but gently lift weights. Walk more. Start with two minutes of walking. Work up from there, right?

Educating yourself about migraine and what works and what doesn’t work, what migraine is, what migraine is not. Making sure that you are eating really well, sleeping really well, hydrating. If the thought of doing VRT again freaks you out so much that you get dizzy thinking about it, don’t go back. Don’t go back. But I would try and find someone in your area who is very trained in vestibular disorders, and then call the front desk and say, how many people with vestibular migraine do they say? And the secretary person at the front probably won’t know but have them give you a callback. Like ask what percent of vestibular migraine does someone see? If it’s not at least 25%, I would try to find someone else. Unless they’re like, I would love to look into this for you, then go see that person.

On your own personal level, do you have some sort of preventative program that’s working for you? Whether it’s lifestyle, medication, some combination of both, like whatever it is, is it working for you? And then the second part is, do you have something when you have an attack? Because it’s not, everyone hates when I say it, but it’s not if, it’s when. Even if you do everything perfectly with migraine, you’re probably still going to have an attack again. And I’ve seen people in group who are like, I went seven or eight months without an attack, and it’s happening now. What the heck did I do wrong? You didn’t do anything wrong. It’s not your fault.

The weather probably did something insane on the same day your period was supposed to start. And you just can’t control that. So take your medication, rest for the day, or use your toolkit, I should say, rest for the day, and then move forward. You’ll be back at your baseline soon. Don’t panic. 

So once you have some sort of system for both acute and prevention, and you’re like, okay, I’m feeling a little bit better. I can function a little bit more. Then maybe you are ready for that. And you have specific things that you want to work on. You want to have specific goals. Like I want to drive. I always say the dishwasher, take a shower, lay flat. Again, that’s a common one people have trouble with. So all of these things, if you have specific goals of what you want to work on, try that. I also know someone recently who’s like, I really don’t want to do VRT, but I keep getting this like sensation, like the ground’s going to slip, slip from under me.

And I want to do stuff with proprioception. Like I want to be able to feel the world better. So I was like, great. Go to a physical therapist and tell them you want to work on exactly that thing, that you refuse to do any head shaking exercises. And she’s like, I can do that. And I was like, yes, you can do that.

Having exact things. Like I want to work on this weird proprioception issue I’m having. I want to work on this specific thing I’m dealing with. Go in it with that mindset so that they can help you specifically because if they don’t know what you want, they’re going to have to decide for you for insurance purposes, for goal setting purposes. And you might not get out of it what you’re actually looking for.

 

O’Brien: We have a lot of people in our audience who are like, well, does it need to worse before it gets better? Or it got so bad that I couldn’t do it anymore. I stopped. If you’re, if you’re doing vestibular therapy for vestibular migraine, do you want it to get bad? Do you want to provoke these things? Do you need to push through? Or is that a sign that like no, like talk to me about that.

 

Oak: I think most of us were raised on like no pain, no gain kind of a vibe. It doesn’t have to be that way. The actual like “gold standard” of how triggering it should be is that you should, you should go no more than three points above your dizziness for no more than 20 minutes at a time.

 

O’Brien: Okay.

 

Oak: So if you are a 3 out of 10 dizzy on a general scale, like most of the time at about a three, okay, great. That’s your baseline. We’re obviously trying to reduce that baseline is the goal, but let’s say you start at three. Zero that out. You shouldn’t go another three above. If you are always at a 7, 8, 9, 10, not the time to start VRT probably, but a 5 or below it might be like, okay, it’s time to maybe think about this again. But if you’re like, okay, I did this, and I’m worse for two days. I’ve now had an attack. I’ve had to take my medication three times from this one day of VRT. No, okay.

Not time. Or you did too much too fast, and you need to tell them. You should always email them. Hey, this may be way worse. Can we think about that next time? And that’s fine too. Maybe you just like shook your head around for 20 minutes, which is not necessary. 

And maybe you should be doing like literally look to your right, look to your left, look back, center, done for the day. If it’s making you feel way worse and you can, no amount of like breathing, grounding, shutting your eyes, opening your eyes, sitting, resting makes it go away in less than 20, 25 minutes, you have done too much, and you need to send your therapist an email.

The first thing a vestibular therapist should teach you is that grounding and breathing is your friend. They should teach you how to do it, give you lots of options for how to do it. There’s not one way to breathe.

There’s not one way to ground, but that is how you teach your body that you are safe again after you do an exercise. So you do the exercise and you breathe and ground, and the breathing and grounding is just as important, if not more important than the exercise you did itself. And you will know if it’s working. We generally say for vestibular therapists, in four to six weeks, something should improve. It shouldn’t be that I’m no longer dizzy. No, that’s not what we’re looking for.

We’re looking for in four to six weeks, I can more easily do something before I get fatigued, before I get more dizzy, before the, I can move around my house for longer before it gets worse. So it’s not, I can now move around for 24 hours a day, no problemo. It’s okay. I could do the dish…I always say the dishes. I could do the dishes for five minutes. Now I can do them for 10 minutes, and then I get dizzy. You’re looking for capacity first and then reduction in dizziness second.

 

O’Brien: That’s super helpful actually because I wanted to talk about what does progress look like? How long do we do things? Because I know in some cases you have eight weeks, that’s what insurance gives you, or you have, you get four sessions, or I will pay for it out of pocket, so I’ll go as long as it takes, but do we want to go, do we want to go eight months? It kind of, what does a program look like, and how do you evaluate along the way?

 

Oak: I think it’s different for everyone. If you have vestibular migraine, you’re probably going to want to stretch those out as far as you can. So you’re still giving yourself a check-in, but you’re not like going all the time.

This is not an every week, twice a week, I tore my hamstring, I went to PT kind of a situation. If they’re forcing you to go every week, twice a week, that is insurance forcing you to go. You do not need to do that check-in that often. So long as you are doing it at home. The biggest reason I like telehealth for vestibular rehab is because a lot of times people are driving 45 minutes, an hour and a half to a PT clinic to do VRT. Okay.

You have just run a marathon on a torn hamstring. I’m going to make you do a hundred pushups and then deadlifts and then squats and make you run home. Like that is insane.

 

O’Brien: Such a good point.  

 

Oak: It doesn’t make any sense for the vestibular system. Driving and being in cars, hard enough. So if that is you, please, please, please ask for telehealth. Most states and most insurances will pay the exact same for telehealth. It doesn’t make a difference. It’s just whether or not the clinic has the capacity. And if the clinic doesn’t have the capacity, find a different clinic further from you who will allow it.

 

O’Brien: Do you think we miss anything since this is your hill?

 

Oak: The hill I will die on. I don’t think so. I guess I just want to reiterate that dizziness gets better. No matter how dizzy you have been for how long, I have had people who have been dizzy for 25, 30 years go into remission. So dizziness gets better. You need the right tools.

You do need the right mindset. You need the right management, but this gets better. There is so much you could do about it. Do not give up hope. A lot of people comment like I’m glass half empty, or I’ve given up hope or whatever. It is really important to maintain hope. See a different provider. I know it can be so difficult, but it does get better. I promise you. I see it happen every single day.

 

O’Brien: Dr. Oak, thanks so much for being with us today. Again, always fascinating and wonderful to talk to you. You put things in such good perspective and help people visualize something that’s really difficult to put into perspective.

So thank you so much for sharing your expertise and your insight with us. 

 

Oak: It is my pleasure. I hope to be back for part three.

 

O’Brien: Would love to have you back. You let me know what you want to talk about. 

 

Oak: Sounds good.  

 

O’Brien: I’ll think of some ideas.

 

Oak: Perfect. Thanks so much, Molly.

 

O’Brien: And that wraps up this episode of Spotlight on Migraine. To our followers, 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. I’m Molly O’Brien. Thanks again for watching. We’ll see you next time. 

 

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