Clinical Example of Migraine Associated Vertigo
3 years ago I met Trisha, a 39 year-old mother of 2 children. She came to vestibular physical therapy with episodes of vertigo that seemed to happen randomly. She would feel spinning 2-3 times per week, and even when she wasn’t spinning she felt off. Her dizziness worsened with things like computer screens, bright lights, and crowded environments like Costco. One of the first questions she asked me was “will I ever be able to go to Vegas again?”, which to this day is one of my favorite questions I’ve ever been asked.
Trisha was suffering from vestibular migraines, a diagnosis similar to regular headache migraines with an added vestibular component which causes vertigo and dizziness. Visual sensitivity (photophobia) is another component of migraines which helped me to confirm the diagnosis.
I frequently treat this diagnosis as a physical therapist working in a Vestibular Rehabilitation Therapy (VRT) clinic. Trisha's path to get to us was one that I have heard many times. She had been to multiple doctors and therapists who could not figure out why she was getting dizzy. She had been diagnosed with Meniere’s Disease and BPPV. She had tried interventions like anti-nausea medications, diuretics, and Epley maneuvers for BPPV without success. She had scans of her head, ear, and heart which did not reveal any findings. After nearly a year of trying to find out the problem, she finally found a Neuro-Otologist and was finally given the diagnosis of Migraine Associated Vertigo (MAV). Her MD then provided her a specific set of supplements and referred her to Physical Therapy to help manage her symptoms. I’m not telling this story to speak poorly about clinicians and doctors, but to emphasize that it can be a long journey because vestibular migraines are a diagnosis of exclusion in medicine, meaning that other potential diagnosis need to be ruled out first.
When Trisha first came under my care she was concerned that this is how she would feel forever, that she would have random bursts of vertigo and she would live in fear that it could happen at any time. She had already started limiting her life to the bare necessities. She was concerned that she would have an attack while driving her children to and from school. Her friends would invite her to social events but she stopped going to things because it was just too much to worry about.
As Trisha’s therapist, I had to first figure out her primary triggers. In other words, I had to find out if there were dietary or lifestyle triggers that were making it more likely that she would experience a spike in symptoms. In her case, there were clear dietary changes that she needed to make (caffeine, food with MSG, and alcohol). Secondly, we incorporated treatment to boost the performance and regulation of her vestibular organs. This included cervical manual treatment to improve head and neck mobility, combined with a specific set of balance exercises that took advantage of the systems in our brain to promote equilibrium and stability. The combination of adjusting her diet and providing manual and exercise interventions was enough to reduce her symptoms over the next 3 weeks. It wasn’t instantaneous, however she felt that she was on the right track right away, and she could feel that she was slowly able to do more and more during the day without feeling off. Each time she came in to therapy we made slight adjustments to her diet and progressed her exercises to match how she felt. Working on her head and neck was done every session which played a large role in normalizing vestibular function. Furthermore, we focused on improving her Vagus Nerve tone through manual therapy techniques and exercise to decrease her anxiety (fight or flight response) and promote a stable resting state.
It took 3 months until Trisha had confidence in her ability to take care of her vertigo without my help. To this day we still keep in touch, and she will update me about her continued progress in achieving normalcy in life again. Yes, she was able to return to Vegas and have a good time with her friends. When she doesn’t manage her triggers she will feel her symptoms creep up, but now she knows to make immediate adjustments so she no longer has big spikes in dizziness or vertigo. It’s now been several months since I’ve seen Trisha as a patient. We still keep in touch and we’ve also run into each other at a concert. Her awareness of her symptoms and knowledge that she picked up while in physical therapy has given her control of her life again.
Now, let’s break down vestibular migraines in more detail.
What are Vestibular Migraines?
Sometimes called Migraine Vertigo, Migraine Vestibulopathy, or Migraine-Associated Vertigo, Vestibular Migraines are the second most common cause of vertigo in the general population. Simply put, they are a specific type of migraine that results in dizziness or vertigo.
Unlike the word “migraine” suggests, a headache is not always present with this diagnosis. Headaches are a possible symptom of vestibular migraines. Other potential symptoms include visual disturbance (photophobia), auditory disturbance (phonophobia), nausea, ringing in the ears (tinnitus), brain fog, and/or a feeling of dissociation (floating, separation from your environment, etc.).
What causes vestibular migraines?
To understand vestibular migraines, we have to understand what a migraine is. A migraine is a brain disorder that involves altered regulation of central nervous system afferents. In other words, the nerves that bring information to your brain misbehave. A typical headache migraine includes symptoms such as one-sided head pain, throbbing, nausea/vomiting, and/or photo/phonophobia. Therefore, we can trace the origin of migraines to structures of our head and brain that have the potential to cause these symptoms.
Our brain is made up of approximately 86 billion neurons. There is constant communication and teamwork between all these neurons in the different sections of our brain.
The neurons of the trigemino-vascular system (TVS) are a likely reason for the symptoms associated with migraines. The misbehavior of various neurons can cause irritation to the blood vessels within the dura of your head causing headache pain. Other neurons can cause over-activation of the thalamus, which leads to an exaggerated pain response or allodynia. In addition, pathways from the thalamus to the cortex may play a role in both photo and phonophobia.
The pathophysiology of vestibular migraines likely also involves the TVS, including the branches of this system that innervate the vestibular organ.
The inner ear receives innervation from ophthalmic branch of the trigeminal nerve. Specifically, the basilar artery and the anterior inferior cerebellar artery (AICA) stems from the ophthalmic branch to supply the inner ear structures. As you may be familiar with, the vestibular organ and the cochlea resides in the inner ear, thus inappropriate activity of these specific nerve pathways may be the key to understanding vestibular migraines.
How can physical therapy help with vestibular migraines?
Your health plays a role in how well these nerves communicate with each other. Things like what you eat, how much you exercise, sleep quality, etc. can all play a role in neural function. In summary, nerves rely on blood vasculature to be supplied with nutrients and allow for optimal performance. Inappropriate activity of nerves or vessels can result in migraine headaches or vestibular migraines. If this nerve inflammation occurs in a pain pathway of your brain, it will cause a migraine headache, while the same inflammation in a vestibular pathway will trigger an episode of vertigo or dizziness.
Head and neck manual interventions have been shown to reduce symptoms associated with both migraines and vestibular migraines. The upper cervical spine shelters the spinal nuclei tract of the trigeminal nerve. Manual interventions targeted toward this area may help to promote normal function and desensitize this neural pathway to reduce migraine or vestibular migraine symptoms. Furthermore, a patient avoiding head and neck movement due to increased dizzy symptoms, will develop cervical musculature tightness and spasms, further exacerbating tension headaches they feel in result of the vestibular migraine.
If you suffer from vestibular migraines or migraine headaches, there is a lot you can do to reduce the frequency and intensity of the attacks without having to take medication. At Ascend Physical Therapy, we specialize in conservative treatment and management of vestibular migraines. We even work closely with doctors when conservative interventions are not enough. We use interventions such as manual therapy, dietary adjustments, designing a vestibular exercise program, and addressing other important lifestyle factors such as sleep and stress management. Each patient’s program is designed specifically for them based on their symptoms. If you suffer with dizziness or vertigo, you do not have to suffer in silence! We are here to help!
Author: Wayne Chen PT, DPT
Dr. Wayne Chen, PT, DPT is a Los Angeles County native. He received his Bachelor of Science degree from California State University, Long Beach where he studied Kinesiology with an Exercise Science emphasis. He then went on to earn his Doctorate in Physical Therapy from the University of Southern California. During his time at USC he accumulated a variety of clinical experiences including orthopedic, neurologic, and vestibular specialties in both inpatient and outpatient settings. As a Physical Therapist he places a large emphasis on improving each patient's function so they can return to doing what they love. He maintains balance in his personal life through fitness and sport, diet, hobbies, friendships, along with enjoying work.
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