Vestibular Rehabilitation And Physical Therapy
Vestibular rehabilitation therapy involves accurately assessing your vestibular dysfunction and providing treatment through advice and education, and a specific exercise prescription. Connecting with a qualified vestibular physiotherapist can provide you with the exercises and tools necessary to gradually reduce your sensitivity to some triggers. It can reduce how often you have an attack as well as decreasing the severity of your symptoms when an attack occurs. Physiotherapy is one of the most effective tools for long-term success in the management of vestibular migraine.
Nystagmus Or Abnormal Eye Movements
Nystagmus refers to uncontrolled movements of the eye, which can be brought on by a specific trigger or completely unprovoked. Although it affects fewer individuals with vestibular migrainearound 20% or lessit can occur during an attack and can indicate clear dysfunction in the vestibular system.2,9 This makes sense too when you consider that vertigo/dizziness, impaired ocular functioning and symptoms like blurry or distorted vision all seem to be connected to one another. And all forms of nystagmus may be an equally-prominent symptom over time in vestibular migraine, even if it was not present upon initial diagnosis.4
Other symptom factors to consider
It is important to remember that vestibular migraine symptoms can vary for each person and may not even be consistent between attacks. While these issues regularly show for patients, they are not a guarantee and there may be additional consequences not even described here. For instance, it is well established that emotional comorbidities are also frequent side effects.
Lastly, we want to emphasize: things can get better. As we noted, migraine generally diminishes with age, even if it does not fully disappear. There are also more and more effective treatments, both for migraine prevention as well as symptom relief . Additional support resources and patient communities offer connection and advocacy opportunities. And researchers continue to investigate new and better ways to help patients all over the world.
Current And Emerging Treatments
Patients who suffer from recurrent migraine episodes may need to be provided with a treatment strategy that includes preventative care as well as a plan for abortive therapy. Neurologists generally use the same 2-pronged approach when taking care of patients who experience recurrent vestibular migraines. When patients have frequent, unpredictable, or disabling symptoms, prevention is certainly an important consideration.
Prevention remains key, and I find antiepileptic drugs or venlafaxine to be most effective, Watson said. If the vestibular symptoms are part of migraine, the prognosis is pretty good. However, not all preventative medications are accessible for each patient, and some treatments that are FDA-approved for migraine prophylaxis are not approved for vestibular migraine, making payer authorization for off-label use in vestibular migraine another impediment.
I generally treat patients who have vestibular migraine prophylactically just like I do regular migraine patients, and it depends what their insurance will approve. Options for prophylaxis include amitriptyline, propranolol, and topiramate. My preferencebut often not approved up-front by insurancewould be 1 of the 3 anticalcitonin gene-related peptide injectables: erenumab , fremanezumab , or galcanezumab , Rebovich said. Other treatments used for prevention of vestibular migraine include flunarizine and cinnarizine, AEDs , beta blockers , antidepressants , and magnesium and clonazepam.4
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How Are They Treated
Thereâs no specific medication for vestibular migraines. Your doctor will prescribe different drugs to stop an attack when it happens. This is called abortive therapy.
- Triptans. Take these migraine meds at the first sign of headache symptoms.
- Vestibular suppressant. It can ease your dizziness and motion sensitivity. This type of drug works on the balance center in your inner ear. Your doctor might prescribe benzodiazepines like lorazepam , anti-nausea drugs like promethazine and antihistamines like meclizine.
- If you have frequent or disabling vestibular migraines, your doctor may try drugs similar to traditional migraine prevention meds. You take these regularly to reduce the severity or frequency of the headaches. These include seizure medicines, blood pressure medicines , and some antidepressants. CGRP inhibitors are a new class of preventive medicine that your doctor may recommend if other medicines donât help.
If you have frequent or disabling vestibular migraines, your doctor may try drugs similar to traditional migraine meds. They include:
There is the possibility of getting relief through use of some devices.
Learn About The Symptoms Treatment Options And Action Steps For This Specific Type Of Migraine That Affects Balance
For many people, a migraine attack includes severe head pain. Its the kind that makes you want to lay in a dark room until it passes. But its important to remember that not all types of migraine look or feel the same. Vestibular migraine, for example, affects your sense of balance. Often during an attack, you can feel like youre moving, falling or spinning when youre actually sitting still. We call this sensation vertigo. Alongside vertigo, a vestibular migraine can also include more typical migraine symptoms such as sound sensitivity, light sensitivity and often ear pain, pressure or ringingbut not necessarily headache. We turned to Dr. Shin Beh, founding director of UT Southwestern Medical Centers Vestibular and Neuro-Visual Disorders Clinic, to give us insight into this particular type of migraine.
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What Are My Treatment Options
Medications may be prescribed to prevent episodes if avoiding triggers does not help control symptoms. Preventative mediations can include a beta-blocker , calcium channel blocker , antidepressant , and/or an anticonvulsant . Treatment with an antidepressant or anticonvulsant does not mean you have depression or seizures they are intended to stabilize the central nervous system and raise the threshold at which attacks are triggered. Medication regimens may be tailored to your existing medical conditions. Once symptoms are controlled, medications may be weaned off and do not necessarily need to be taken forever.
Vestibular rehabilitation is a type of physical therapy that may also be recommended to treat chronic balance dysfunction. Vestibular therapy will train your brain to desensitize itself to common sensory triggers. The course of therapy is often gradually increased in its intensity and can be widely varied to combat multiple types of triggers that include movement, visual perceptions, and posture instability.
Treatment to help stop a vestibular migraine attack once it begins includes rest, observation, hydration, and medications such as anti-nausea, antihistamine, or sedatives if needed. However, the most effective way to treat vestibular migraine is preventing an attack as described above, and it is critical to recognize your triggers. Many cases can be treated with trigger avoidance alone.
Further Information About Vestibular Migraine
Please contact us for further information about vestibular migraine or to chat with a member of our team. Further information about vestibular migraine is also available at vestibularmigraine.co.uk .
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Clinical Evaluation And Diagnostic Criteria
Diagnostic criteria have been established only relatively recently, in 2012.5 While neurologists and other specialists have been diagnosing and treating vestibular migraine prior to the formulation of these guidelines, these parameters offer a more standardized approach
that can be used across multiple specialties and disciplines.
Despite the existence of formal criteria, however, a number of hurdles exist when it comes to diagnosis of this disorder. The challenges related to diagnosis of vestibular migraine lie in its relatively broad spectrum of manifestations, the absence of typical migraine headaches with vestibular symptoms, and its very recent definition as a distinct entity, Huang and colleagues wrote.1
“With regular migraine, we can usually proceed directly to treatment based on history and exam alone. The difficulty is that the symptoms of vestibular migraine can appear to represent posterior circulation stroke, transient ischemic attack, or peripheral vestibulopathy,” said Gayle Rebovich, MD.
Sometimes, patients are started on empirical treatment without a definitive diagnosis, and in some cases, a treatment response may help direct diagnostic decision making. We may try a course of vestibular therapy to see if they derive any benefit from that. If not, this supports the diagnosis of vestibular migraine, Rebovich added.
What Lifestyle Changes Or Therapies Can Help With Vestibular Migraine
You may be able to reduce the number and intensity of your vestibular migraine attacks by keeping a consistent sleep routine, eating on a regular schedule , managing stress, and getting enough exercise, according to Johns Hopkins Medicine.
While its important to recognize migraine triggers, you dont want to avoid everything as a coping mechanism, says Mueller. Cognitive behavioral therapy can help people to learn manage stress and live with migraine and vertigo, she says.
Some people may benefit from vestibular rehabilitation , which is like physical therapy for people who have issues with vertigo and dizziness, says Mueller. VR is an exercise-based program that is designed to help train the nervous system to compensate for vestibular problems, according to the Vestibular Disorders Association.
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A Swirly ‘morning Routine’
Some people say their first thoughts on waking are of coffee, or what they are doing that day. My first thoughts are always of what my body is doing in terms of pain or dizziness. Does it feel as though I am moving? Is my head swirling? Can I lift it off the pillow without too much difficulty?
Mornings then take a little longer than they used to. Jumping out of bed is never going to happen as I would likely have a head swirl, lose my balance and end up on the floor. Instead, there is a tentative sitting up, then each foot is placed gingerly on the floor. Standing is done with care, depending on symptoms.
Definitions Of Migraine And Vertigo
Migraine headaches are recurrent headaches that are often accompanied by nausea and light sensitivity and that are separated by symptom-free intervals. The headaches typically have a throbbing quality, are relieved after sleep, and may be accompanied by visual symptoms, dizziness, or vertigo. Patients often have a family history of migraine.
Migraine can be divided into 2 categories: migraine without aura and migraine with aura .
Vertigo is an illusion of movement of the environment or of the patient in relation to the environment.
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What Are Vestibular Migraine Symptoms
Symptoms of vestibular migraine can differ slightly amongst those with the condition. Two of the most common are dizziness, which VeDA describes as ‘a sensation of lightheadedness, faintness, or unsteadiness’, and imbalance, which is ‘unsteadiness or loss of equilibrium that is often accompanied by spatial disorientation’.
Other symptoms of vestibular migraine in particular, and those that affect me, are motion intolerance , vertigo attacks , and issues with heights or simply looking at tall buildings. Cobblestone streets and uneven ground throw out my balance, and you will never catch me going on a rollercoaster!
For more on this, my post vestibular migraine triggers: managing time in the city may be helpful!
And for more on life with vestibular migraine, the article summary on vestibular migraine by VeDA is very informative.
What Are Triggers For Vestibular Migraine
Vestibular migraine triggers vary depending on each individual. What may kickstart an episode for one person may have no effect on another. However, here is a list of the more common triggers reported by our patients:
- Weather changes
- Poor sleeping patterns or not enough sleep
- Bright lights
- Onset of menstrual cycle in women
- Excessive movement stimulation
- Disorienting visual stimulation
- Specific food choices
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Articles On Migraine Types
There are many names for this type of problem. Your doctor might also call it:
- Migraine-associated vertigo
A Day In The Life With Vestibular Migraine
When my symptoms of vestibular migraine are playing up I often watch mindless YouTube videos. Or, if dizziness means watching isn’t possible, then I simply listen to them. ‘Day in the life’ videos on YT are often full of glossy images. People sipping an iced latte in the sun or wandering down a beach. But my day in the life with vestibular migraine is somewhat different . . .
A day in the life as a ‘vestie’ is unpredictable. There isn’t a regular day because symptoms fluctuate and you don’t really know what will happen hour to hour. I wrote this on a more difficult day. Thankfully they are getting less, but one always comes along at some point.
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Who Gets Vestibular Migraines
Migraines can affect anyone but are more common in females than males. Migraines also have a tendency to run in families. Some patients report that their migraines are triggered by:
- hormonal changes e.g. menstruation or menopause
- quick movements of the head or body
- being in a crowded or confusing place
- driving or riding in a vehicle
- watching movement around you eg on TV.
What You Need To Know
- Vestibular migraine can cause vestibular or balance symptoms with or without an actual headache.
- There is almost always a history of motion sensitivity since childhood, and migraine headaches at some point in the person’s lifetime, even if they last occurred decades ago.
- Vestibular migraine isnt fully understood but seems to result from overlapping pathways that modulate pain and vestibular inputs into the brain.
- Many of the triggers for migraine headaches can cause a vestibular migraine.
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What Is A Vestibular Migraine
Migraine can affect the vestibular system of the inner ear, which impacts the way the brain controls balance and the way a person experiences the space around them. When this system does not work properly, a person may experience feelings of vertigo, unsteadiness, or dizziness that can be triggered by movement.
A doctor may think a person has vestibular migraine when the person experiences these kinds of symptoms for minutes or hours.
A person with vestibular migraine may also have a history of migraine headaches. About 40% of people who suffer from migraine headaches also have vestibular symptoms. However, a person can also experience vestibular migraine without headaches.
Vestibular migraine can cause a feeling that the ground is moving or falling, or cause problems coordinating movement. It can also impact the senses and distort hearing.
Other than a headache, symptoms can include:
- sensitivity to light, sound, or smell
- nausea or vomiting
- discomfort turning, bending down, or looking up
- feeling of pressure in the head or the ear
- ringing in the ears, known as tinnitus
- partial or complete loss of vision
- visual disturbances, such as flashing lights, spots, or blurring
These symptoms can vary in severity. There may be warning signs that vestibular symptoms are about to happen. A person may see flashing lights or other visual disturbances, a phenomenon also known as an aura.
Vestibular Migraine Vs Menieres Vs Bppv
There is a connection between Vestibular Migraines and other vestibular disorders including BPPV and Menieres Disease. One medical study noted that nearly 30% of those with Menieres disease also meet the criteria for Vestibular Migraine. And similarly, up to 18% of those with vestibular migraines ended up with the low frequency hearing loss commonly associated with Menieres disease. Studies also show that BPPV is the most common vestibular condition and is also more likely to exist in patient who suffer from vestibular migraine.
Both BPPV and Menieres Disease commonly involve attacks or episodes of vertigo and nystagmus , similar to the vestibular symptoms that occur with vestibular migraines. Therefore, these conditions are often confused for one another, and can be difficult for medical professionals to differentiate.
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How Is Diagnosis Made
If referred to a specialist by your GP, a diagnosis of your condition will be made based on your medical history, answers to questions about when and where the symptoms occur, and a physical examination.
Your doctor may order various tests to rule out other balance disorders. These may include scans or specific tests of the balance portion of the inner ear and brain.
What Treatment Guidelines And Pain Relief Options Are Available For Vestibular Migraine
Those are the same treatments that are used for migraine certainly for the pain that’s associated with vestibular migraine. The more important question is: Are there specific therapies either symptomatic therapies to address vestibular symptoms or specific acute or preventive migraine therapies that are more indicated in someone with vestibular migraine?
There is some experience indicating that certain specific medication approaches may be more effective in those with vestibular migraine one of those is acetazolamide, which has the brand named Diamox. This is a mild diuretic that works on an enzyme that’s believed to influence fluid balance in the inner ear. It would most likely be used as an acute therapy, for a day or two, to treat specific attacks.
Significant vertigo is a situation where benzodiazepines, like lorazepam, are sometimes used. However, these medications should be used cautiously due to the risk of physical dependence, addiction, and withdrawal effects.
There’s some notion that attacks of vestibular migraine might be triggered by bouts of high sodium intake. So a low sodium diet might also be considered.
One final note that is of interest is based on the idea that there’s CGRP in the vestibular system: There’s active interest in the possibility that the therapies that are specifically targeting CGRP the gepants and the monoclonal antibodies may be ones that are particularly effective for vestibular migraine.
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