Victory Over Vestibular Migraine

Victory Over Vestibular Migraine

Metadata

Highlights

Vestibular migraine is an invisible illness. — location: 114

It does not care about your job. It does not care about your friends. It does not care about your family. It does not care about your life. — location: 116

Sucking it up and soldiering on does not work. Trying to appear normal does not work. Willing it away does not work. — location: 150

Vertigo is defined as the illusion of motion, either of self, or the environment. — location: 195

It encompasses a variety of sensations including tumbling, falling through space, rocking, swaying, bobbing, swimming, shimmering, floating, ground-shifting, and jolting. The most evocative description a patient gave me as ‘it feels like the devil has grabbed me by the arms and is throwing me around”. — location: 197

head motion-induced vertigo is vertigo that occurs during head movement. Positional vertigo is vertigo that occurs once the head assumes the offending head position (not during head movement). Visually-induced vertigo is vertigo that is provoked by complex, busy, distorted, or moving visual stimuli. — location: 201

Dizziness is defined as non-specific disorientation without the illusion of motion. — location: 204

It is a more general and broad term that encompasses feelings like disorientation, discombobulation, lightheadedness, or “tipsy”. — location: 205

feeling like one is not wearing the right pair of glasses, feeling “off” or feeling as if “things are not right”. Some describe feeling like their brains are vibrating, wobbling or jiggling like jell-o. — location: 206

Postural symptoms are defined as balance symptoms related to maintaining an upright posture. — location: 215

Visual Lag is the sensation that the eyes don’t follow movements of the head. — location: 230

It can be understood as a sensation that the visual environment takes a tad longer to catch up with a head movement. — location: 231

Movement-induced blur is a momentary disturbance in visual acuity during or just after head movement. — location: 233

Vertigo is not a diagnosis. Vertigo is a symptom, just like a swollen arm. — location: 239

Details make perfection, and perfection is not a detail. Leonardo da Vinci — location: 243

Some examples include ear pressure (fullness), tinnitus (ringing in the ears), muffled or loss of hearing, headache (describe the quality, location, aggravating factors, relieving factors), light sensitivity, sound sensitivity, difficulty thinking, vision changes, nausea, vomiting, sensory changes (numbness, tingling), motor changes (muscle weakness), and difficulty speaking. — location: 263

Is there a specific head position or movement that provokes it? Is it triggered by pressure maneuvers, like coughing, sneezing, bearing down, and lifting heavy objects? How about migraine triggers (discussed in a later chapter)? — location: 267

if you have had any tests (e.g., CT scan, MRI, lab tests, hearing tests), be sure to have a record on hand. For CTs and MRIs, ensure that you have a copy of the CD with the images (radiology centers often provide these, but be sure to ask). — location: 270

attack can be divided into four phases: premonitory, aura, attack, and postdrome. — location: 297

headache. — location: 298

Migraine is not just a headache. — location: 303

While headaches are a common symptom of migraine, they can manifest and impact a person in many other ways. — location: 305

Migraine is a complex neurologic disorder arising from metabolic and biochemical derangements that affects multiple brain regions that control sensory, autonomic, emotional, cognitive, and even motor, function. — location: 306

Vestibular migraine is a type of migraine that predominantly manifests with vertigo and dizziness. — location: 346

While headaches may occur with vestibular migraine, headaches are not the most significant feature. — location: 346

Instead, vertigo and dizziness are the main, and most disabling, symptoms of the disorder. — location: 347

Stress and trauma play very large roles in migraine. — location: 385

and has a big part in migraine genesis; many of my patients experienced their first vestibular migraine attack during periods of unusually high stress. — location: 392

The word pathophysiology refers to the dysfunctional physiological processes that underlie a specific illness. — location: 439

Brain fog is a term that describes difficulty thinking. It may feel like it takes much longer and more effort to mentally process anything. — location: 693

Fatigue can occur during migraine attacks but usually hits during the postdrome. My patients often describe feeling utterly drained and exhausted after an attack. — location: 695

Word-finding difficulties refer to trouble speaking during a migraine attack. — location: 700

Word-finding difficulty refers to the phenomenon where a person uses the wrong words, garbles a sentence structure, speaks gibberish, and/or finds it extremely hard to think of and use the appropriate words. — location: 702

depersonalization (a feeling that one becomes detached and is no longer part of reality), — location: 723

derealization (feeling like the world and one’s surroundings become unreal). — location: 723

It is very interesting to note that Lewis Carroll himself suffered from migraine, and may his own migraine-related somesthetic misperceptions may have inspired the fascinating tales in his novel — location: 745

Ginger’s most well-known attribute is its anti-nausea properties. — location: 1782

Melatonin is the “clock neurohormone” secreted in the pineal gland of the brain that helps with sleep. — location: 1891

Menthol is naturally found in mint plants like peppermint and spearmint. — location: 1935

Peppermint oil has been shown to help reduce the severity and duration of a migraine attack. — location: 1937

For acute vestibular migraine episodes, one should apply a few drops of peppermint oil to the forehead or temples, or put a few drops of peppermint oil in a bowl of hot water and inhale the steam. — location: 1938

Turmeric — location: 2002

Curcumin is the main bio-active phytochemical found in turmeric. Curcumin has antioxidant, anti-inflammatory and pain-relieving properties. It can improve cognitive function, fatigue, and mood as well [Cox, 2015]. — location: 2004

Life is like riding a bicycle. To keep your balance, you must keep moving. Albert Einstein — location: 2198

activity are vital for brain health. Physical inactivity is a major cause of depression, anxiety, pain, cardiovascular disease, and dementia. — location: 2202

Vertigo and dizziness cause a lot of discomfort with movement, and as a result, many people restrict their physical activities. Unfortunately, this decreases the brain’s tolerance for movement, and inactivity will eventually result in more dizziness when a person tries to resume physical activity. — location: 2203

Exercise progression is an important principle to remember. You need to tailor your exercise program based on what you can tolerate. — location: 2211

Exercises that are too challenging will make you horribly dizzy, discourage you, and erode your motivation, and may even trigger a vestibular migraine attack. Exercises that are too simple are unhelpful. — location: 2212

You must choose exercises at a level of intensity that is achievable but challenging. Try to test and expand your limits in steps. — location: 2216

Rate your discomfort or dizziness with each stage on a scale of 0 to 10 (0 meaning no dizziness/discomfort, and 10 indicating the worst ever dizziness/discomfort). Once you find that a particular stage results in causes dizziness/discomfort at a 0-3, you can move on to the next stage. Do not proceed if the dizziness/discomfort is more than 5. Perform the exercises more slowly if you find that the dizziness/discomfort is above 8. — location: 2233

Aerobic exercise has positive effects on migraine and vestibular migraine. Studies have shown that aerobic exercise improves vestibular migraine and migraine severity, AND lowers blood levels of pro-inflammatory compounds. — location: 2314

Aerobic exercise does NOT have to be a heart-pounding, sweat-drenched ordeal that takes you to the borderlands of life and death. — location: 2316

Activities that count as moderate intensity exercises include jogging, brisk walking, elliptical training, cycling under 10 mph, swimming, water aerobics, and dance classes. A slow stroll around the neighborhood does not count, sorry. The studies found that 30-45 minutes of such activity (not including warm up and cool down), three times per week was enough to obtain benefits for migraine and vestibular migraine. In fact, migraine improvement with such an exercise program was comparable to that achieved with topiramate or tricyclic antidepressants. — location: 2320

Start with brisk walking. As your endurance and tolerance improves, you can try jogging, swimming, or cycling. Stationary bicycles, treadmills, and stair-masters are good indoor options. — location: 2324

Low impact, low velocity exercises can be immensely helpful for people suffering from dizziness. These exercises also produce minimum stress on your joints. In addition, these exercises improve your flexibility, reduce anxiety, relieve stress, and help your brain reduce its sensitivity to the many head, eye, and body movements that cause dizziness. — location: 2379

A recent study showed that yoga was effective at reducing the frequency and severity of migraine attacks. — location: 2383

Tennis, pickleball, racquetball (squash), table tennis, and badminton are some examples of sports that can be aerobic exercises that also improve dizziness and balance. — location: 2391

Dancing is a fun way to improve one’s balance and reduce dizziness. — location: 2399

that cause dizziness, vertigo or imbalance; for example, if a person gets dizzy with head movements, a vestibular therapist will work on exercises that progressively reduce the brain’s sensitivity to head motion. — location: 2409

In vestibular migraine, VRT exercises focus on adaptation, and desensitization. These are called habituation exercises and gaze stability training, designed to help decrease the constant dizziness, visually-induced dizziness, a sensation of vision “jumping”, and head motion-induced dizziness. Such exercises are intended to stimulate mild to moderate dizziness, and over time, the brain becomes more resilient and the dizziness will decrease. — location: 2413

In general, I find that VRT works best for vestibular migraine once we start a person on the appropriate prevention therapy to “cool” the hot migraine brain first. If VRT is performed when the brain is in a very sensitive and hyperexcitable state, even the mild dizziness produced by VRT may be too overwhelming, and could aggravate vestibular migraine. — location: 2417

When you undergo VRT, you must be disciplined, diligent, and motivated to perform these home exercises to guarantee the best possible outcome. — location: 2422

Chronic long-term stress, however, is much more insidious and harmful. Dysfunctional family circumstances, ongoing financial hardship, and unreasonable job circumstances are all sources of chronic stress. With chronic stress, the flight or fight response is almost perpetually turned on. Levels of cortisol are chronically elevated, disrupting the body’s metabolic state – raising blood sugar levels, elevating blood lipid levels, altering sleep patterns, triggering cravings for sugary foods (which can provoke migraine), raising blood pressure, unleashing pro-inflammatory processes, suppressing the immune system, and disrupting other hormones critical to our homeostatic well-being. The net result is a jittery brain vulnerable to pain, vertigo, anxiety and depression, and a body prone to obesity, diabetes, heart disease, cancer, infertility, infections, autoimmune disease, and stroke. Like the proverbial frog being slowly boiled alive, chronic stress simmers around you until it eventually reaches a boil with terrible consequences. — location: 2483

Hyperacusis (sensitivity to sound) occurs during and in between vestibular migraine attacks. Loud sounds and noisy environments are not only unpleasant to vestibular migraine patients, but can also trigger the attacks. Sirens are a particularly obnoxious trigger. — location: 2538

Although it is usually unpleasant and nauseating, motion sickness can trigger a full-blown migraine attack if it is severe enough. — location: 2598

If you have motion sickness, taking preventive measures prior to travel can help ward off a vestibular migraine attack — location: 2599

Irregular sleep patterns are a common vestibular migraine trigger. — location: 2605

triggers the attack. — location: 2606

While some experience vestibular migraine attacks the morning after a night of poor sleep, a study in migraine patients showed that most attacks tend to happen the following day. — location: 2606

Interestingly, sleeping in can also trigger migraine attacks. “Weekend migraines” or the “Saturday syndrome” occur in people with regular 9-to-5 jobs. These are migraines that begin on Saturday mornings, particularly after a hectic week. One explanation for these migraines is the change in sleep pattern. Sleeping in is a wonderful luxury, but not good for the hot migraine brain. — location: 2607

Engaging in activities that require a lot of back-and-forth head movements is not only uncomfortable, but can trigger vestibular migraine attacks in some people. — location: 2614

Missing or skipping meals can often trigger vestibular migraine attacks. — location: 2623

An ounce of prevention is worth a pound of cure Benjamin Franklin — location: 2646

Regular, proper sleep is essential for people with vestibular migraine. — location: 2671

Try not to nap during the day — location: 2675

Turn the clock away from you. There is nothing worse for sleep than staring at the clock, and counting how many hours or minutes you have left before you have to wake up and get ready for the day. — location: 2692

Get more light during the daytime. This will promote a healthy sleep-wake cycle. — location: 2694

Chamomile has the additional benefit of reducing depression and anxiety. — location: 2708

Regular meal time is important. Avoid skipping meals. If you do not have time for a lunch break at work, try to have some healthy snacks at hand. — location: 2711

Drinking more water can actually reduce migraine attacks. — location: 2718

Important

If you are working out, ensure that you sip on water throughout your workout. It can be useful to drink more fluid prior to your workout to buffer against fluid loss during exercise. — location: 2723

Adding natural water flavoring/enhancers, can encourage you to drink more water and limit sugar intake. If you are taking topiramate or zonisamide, ensuring adequate fluid intake is very important to prevent kidney stones, and heat stress from reduced sweating. — location: 2726

Explore

Remember, by the time you feel dehydrated, it’s too late, and you are already vulnerable to a migraine attack. — location: 2730

Green light tends to be the least provocative for migraine, and may enhance the mood. — location: 2739

If possible, using green LED lights at home may help. Dr. Ramy Burstein, who described these interesting findings, developed the Allay Lamp that emits a pure green light. — location: 2740

Lower the brightness of electronic screens as much as possible. If you can, use “dark mode” for these devices. — location: 2747

Lying in bed checking social media and email just before sleeping is a no-no. — location: 2753

View your TV from at least 8 feet away. — location: 2762

Avoid using earplugs that muffle all sounds. — location: 2782

stress is a silent killer. It is impossible to avoid stress. However, — location: 2828

Time management. Stay ahead of stress by prioritizing tasks and organizing our days. Don’t let the demand of daily tasks overwhelm and drown you. — location: 2837

within hours. — location: 3006

Tyramine is the by-product of tyrosine (an amino acid) breakdown. It is a known migraine trigger, — location: 3020

There are migraine superfoods that you should embrace. — location: 3200

These contain nutrients that help control migraine, antioxidants that decrease inflammation (a huge part of migraine pathophysiology), and many other health benefits. — location: 3201

That no one dies of migraine seems, to someone deep into an attack, an ambiguous blessing. Joan Didion — location: 3766

Gammacore, Cefaly, and timolol eye drops also work as both migraine preventive and rescue agents. — location: 3807

Clonazepam (Klonopin) has a half-life of about 18-60 hours, reaches peak plasma concentration 1-2 hours after oral administration, and a duration of action of 6-12 hours. — location: 3999

(Benadryl, pregnancy category B) is an antihistamine that can be used during migraine attacks. — location: 4035

Drink fluids. Dehydration often triggers a migraine attack, and adequate hydration can help mitigate the attack. — location: 4081

sleep can help terminate an attack. — location: 4084

Try menthol-containing topical products. — location: 4086

Typical locations include the back of the neck at the base of the skull, and the temples. — location: 4086

Peppermint oil is a natural source of menthol. Other menthol-containing topical applications include Mentholatum, Vicks, and Icy Hot. — location: 4087

magnesium and ginger root. — location: 4089

Pink noise therapy. Pink noise closely matches the spectrum of everyday noises. Pink noise therapy can help improve tolerance for everyday noises over time. — location: 4112

There are no specific treatments for migraine-related brain fog, unfortunately. — location: 4145

The good news, however, is that controlling migraine with the appropriate preventive therapy, often leads to improvement of this awful symptom. — location: 4146

Poor sleep quality causes fatigue, and excessive daytime sleepiness that worsens brain fog. — location: 4150

exercise improves brain functions, reduces inflammation, promotes better sleep, and stimulates the release of chemicals that enhance cognitive function. — location: 4152

Routine is important, and can help eliminate the need to expend precious mental energy on decisions. — location: 4166

Learn to say no; save your mental energy for important tasks, and turn down tasks that are not essential. — location: 4171

compresses — location: 4244

Anxiety and depression are common comorbid disorders in migraine. — location: 4251

Exercise is one of the best ways of treating depression and anxiety. — location: 4254

Caffeine worsens anxiety significantly. — location: 4259

Chamomile tea can help improve depression, anxiety, and insomnia. — location: 4265

Mindfulness can help improve mood and stress-coping mechanisms. — location: 4274

Persistent Postural Perceptual Dizziness (PPPD) — location: 4277

I often find that treating the vestibular migraine leads to improvement in PPPD symptoms in most. — location: 4278

SSRIs or SNRIs are typically used to help treat PPPD. — location: 4280

Vestibular rehabilitation therapy (VRT) is one of the main treatments for PPPD, and can be highly useful — location: 4285

An ounce of prevention is worth a pound of cure. — location: 4372

Do not consume a heavy meal, caffeine, alcohol, or foods high in histamine (e.g., cheese, cured meats) right before a trip. — location: 4374

Stay hydrated. Make sure you consume enough water. — location: 4376

If riding in a car, sit in the front seat. — location: 4379

Focus on the horizon as much as possible, especially at the beginning of the trip. — location: 4380

visual input by wearing sleep eye masks (not when you’re driving of course!). — location: 4383

Controlled slow deep breathing and mindfulness breathing exercises can suppress motion sickness. — location: 4386

Buckle yourself in a seat with a solid back and headrest — location: 4389

Ginger is an effective anti-nausea agent. Taking ginger before a trip, or consuming crystallized or candied ginger during a trip, may be effective. — location: 4395

High dose (1000 mg) vitamin C can prevent motion sickness when taken before a trip — location: 4397

Smelling certain essential oils can help relieve motion sickness as well [Keshavarz, 2015]. Peppermint oil is especially useful, but others that may help include rose, eucalyptus, and lavender oil. You can try applying a small amount on the forehead and, if you like, just above the upper lip. — location: 4399

Men with chronic migraine — location: 4639

In men and women with vestibular migraines and migraines that are difficult to control with preventive medications, it may be prudent to check testosterone levels. If these levels are low, working with a urologist, endocrinologist, or gynecologist on testosterone replacement may have life-changing results. — location: 4643

If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment. You have power over your mind, not outside events. Realize this, and you will find strength. Reject your sense of injury, and the injury itself disappears. Marcus Aurelius, Meditations — location: 4657

Chronic vestibular symptoms in conditions like vestibular migraine certainly impact a person’s emotions and mental state, causing substantial long-term harm. — location: 4662

The ability of our brains to re-wire and re-organize, essentially by forming new synapses and disconnecting old ones, is called neuroplasticity. — location: 4683

Tinnitus is a prime example of maladaptive (i.e., bad) neuroplasticity. — location: 4690

Refusing to believe that you will get better, being physically inactive all day, disbelieving that medications can help (“I’m too sensitive for any medication”), and accepting defeat (“I’m just going to be disabled”) is “downwiring” and will lead to chronification and worsening of vestibular migraine. Central Sensitization Syndrome ​Central sensitization is the result of maladaptive neuroplasticity. It is a state where the brain amplifies and devotes too much attention to a specific sensory input. This state is well described in pain disorders, including fibromyalgia, IBS, pelvic pain syndromes, interstitial cystitis, and TMJ syndrome. They are more common in people with depression, anxiety, PTSD and migraine, and also share overlapping symptoms like fatigue, sleep disruptions, and brain fog. ​As a result of maldaptive neuroplasticity, the brain becomes more alert for specific stimuli it perceives as threatening. This ever-increasing awareness feeds a vicious cycle of symptom hypervigilance, anxiety, and perceived threat. The brain is on high alert to even the slightest hint of the symptom. For example, in chronic migraine, central sensitization amplifies the brain’s sensitivity to pain to such a degree that non-painful stimuli (e.g., touching one’s hair) are perceived as agonizing pain (a condition called allodynia). In vestibular migraine, frequent attacks of vertigo and dizziness cause the brain to fear anything that could provoke dizziness. It grows anxious and hypervigilant of any stimuli that could make it dizzy. If visual motion causes dizziness, central sensitization causes the brain to become extremely vigilant of movement in the visual field; the slightest unexpected movement in one’s visual periphery sends the brain into a frenzy. This constant state of high alert is the brain’s coping mechanism, an attempt to protect itself from what it considers threatening, but unfortunately, this only fuels a vicious cycle of exponentially-increasing dizziness. ​Personality also plays a role in aggravating central sensitization. Most people with migraine are type A personalities and perfectionists. They tend to be very self-critical when they don’t attain the goals they set for themselves. When vestibular migraine disrupts the ability to accomplish job activities, and family and social engagements, frustration and anger simmer. Most people bottle up their frustrations, rather than express these emotions healthily, and this pent-up, self-directed anger aggravates central sensitization. — location: 4709

Mindfulness refers to “conscientiously being in the moment” by being fully present, and carefully paying attention to the experiences of the current moment. — location: 4732

The opposite of mindfulness is mindlessness, which is essentially being on autopilot and allowing your mind to wander in any direction it likes. — location: 4734

Mindlessness occurs when you are watching a television program or browsing social media while having dinner, and end up finishing the meal without really tasting it. — location: 4737

A simple exercise in mindfulness is to eat a small meal alone. No phone, no TV, no distractions. As you eat it slowly, notice the colors, flavors, textures, and temperature of each bite. How does each bite make you feel? That meal would have been the most pleasurable experience for many people. It highlights the power of mindfulness, being in the moment, and fully immersing yourself in the present. — location: 4738

Mindfulness can help improve your awareness of your body and emotions. This awareness of your internal state of being is called interoception. You will notice unpleasant sensations, heart rate, breathing, and muscle tone. You will learn how to recognize changes in your internal state of being. — location: 4741

Multiple studies have confirmed the power of mindfulness on chronic illnesses, including migraine. — location: 4746

People with vestibular migraine can benefit immensely from mindfulness. It improves your resilience to stress, helps your cognitive abilities, breaks the dizziness-anxiety cycle, enhances your sense of well-being, and brings you into harmony with your body. It re-directs your attention from worrying about how the dizziness and vertigo are making you feel miserable, to why you feel that way and about how to manage it. — location: 4747

Metacognition refers to the process of analyzing your thoughts in a detached manner; you become your own “therapist”, and “think about how you think”. Metacognition can help you gain awareness of your strengths, and weaknesses, while arming you to manage negative thoughts and emotions. — location: 4766

Regardless of your faith, prayer is an effective therapy for improving the quality of life and well-being in chronic illnesses, including cancer and migraine — location: 4862

A fascinating study found that that praying actually changed the brain activities in people with depression, breaking the link to the trauma that triggered their depression in the first place — location: 4864

Spiritual meditation has been shown to reduce migraine frequency — location: 4866

Visualization is a scientifically proven method of improving your performance and abilities. — location: 4918

The brain uses visualizations to simulate future experiences, priming the neurons and brain regions responsible for controlling a specific activity for optimal performance when the time comes. Visualization can improve your confidence, motivation, and ability to achieve a specific goal. — location: 4919

You can use visualization to your advantage when it comes to exercising or performing any activity you feel may make you dizzy. Before performing a vestibular exercise, visualize yourself going through that entire exercise, executing it perfectly. — location: 4921

Unfortunately, you will encounter people who may doubt your symptoms and illness.  Such is the fate of those afflicted with chronic invisible illnesses. — location: 5076

won’t understand the unabashed power of a community until you’re a part of one Anonymous — location: 5122

Work As a general rule, your approach should be: don’t ask, don’t tell. — location: 5325