What is vestibular physiotherapy?

Vestibular rehabilitation is an exercise-based therapy targeting vestibular symptoms that do not go back to normal between episodes of vestibular migraine. For example, if vertigo or imbalance is still an issue after a crisis, exercises could improve steadiness and get rid of the vertigo. 

I have been referred to vestibular physiotherapy. What should I expect during the evaluation? 

All evaluations start with a questionnaire, including symptoms, past medical history, medications and former test results. There is also an evaluation to assess the vestibular contribution to your symptoms during head and body movement. Balance evaluation is also part of the routine evaluation for vestibular migraine. The evaluation is tailored according to your clinical history and symptoms. Great care is taken not to provoked to much symptoms. The most important parts of the evaluation is helping you to set the goals that you want to achieve, and planning the treatment.

Can any physiotherapist do vestibular physiotherapy? 

You should look for a physiotherapist with specific training. Physios offering this approach usually have a special interest in vestibular rehabilitation and followed specialized courses during professional continuing education program.

Should I do the evaluation during a migraine attack? 

During an acute attack, the aim is to stay calm and avoid all unnecessary movement, the same as a regular migraine, meanwhile trying to rapidly abort the symptoms, if possible. An evaluation in that condition will probably be not very productive, not well tolerated and not useful since the diagnostic of vestibular migraine is based mainly on the history.

What type of problem can be treated with vestibular physiotherapy? 

Balance issues, including dizziness when attending busy, complex or contrast visual environment and positional vertigo is usually well treated with vestibular physiotherapy. 

Sensation of constant imbalance, discomfort or nausea provoked by head or body movement, have less favorable outcomes.

How does vestibular physiotherapy work?

Depending on the type of exercises chosen for you, different areas of the brain will be involved to reestablish neuronal connections or to tone down the abnormal brain responses in order to regain vestibular reflexes and pathways that have been set aside or are currently ineffective. 

If I suffer from vestibular migraine, will vestibular physiotherapy help me? 

Vestibular physiotherapy is usually an important part of the treatment management of residual symptoms once the medication to reduce or control the crisis of vestibular migraine is optimal. The success will depend on your level of autonomic sensibility (in other words if you are easily nauseated) and ultimately on how well you can tolerate physical activity. 

What type of exercises can be done for vestibular migraine? 

Many types of exercises can be done and they are tailored to fit your goals. 

• Balance exercises aim at reducing your instability and dizziness
• Habituation to reduce positional vertigo and dizziness related to intolerance to head movement
• Specific maneuvers for benign paroxysmal positional vertigo (BPPV) often associated to vestibular migraine
• Visual exercises using movements of the eyes (oculomotor)

How long should I do the exercises before I see an improvement? 

It is highly variable and depends on the symptoms that are treated. For example, positional vertigo is usually treated in a few sessions but, for balance, it could take a few weeks to see an improvement with a home-based program. 

People with vestibular migraine may take more time to improve than people without migraine because their brain does not «habituate» as fast. 

Will I need do to exercises all my life?

Usually these exercises are used only if, between episodes of vestibular migraine, the symptoms do not return to baseline level. Once they have returned to normal, the exercises are not needed anymore. But for some persons they could be practiced a few times a week for maintenance.  

I am often told that anxiety makes dizziness worse. Is it true and what can I do about it? 

Anxiety makes everything worse. The best way to get control over anxiety is to use what ever have works best for you in the past to reduce your level of stress in other aspects of your life. A very common mechanism that will end up increasing vertigo, dizziness, unsteadiness and nausea when stressed, are changes in the speed and depth of breathing pattern, mainly faster speed and shallow breathing. That will only lead to more symptoms. Learning to identify those changes in oneself is very useful.  Breathing exercises could also be learned. 

In summary, vestibular physiotherapy can be a very useful process if you live with vestibular migraine. It may take time and effort, but could pay off on the long term. 

REFERENCES

Alghadir A, Anwer S. Effects of vestibular rehabilitation in the management of a vestibular migraine : a review. Front Neurol. 9 440. 2018.

Sugaya N, Arai M, Goto F : Is the headache in patients with vestibular migraine attenuated by vestibular rehabilitation ? Front Neurol. Avril 2017.

Vitkovic J, Winoto A, Rance et coll : vestibular rehabilitation outcommes in patients with and without vestibular migraine. J Neurol. Vol 260, pp : 3039-3048. 2013.

Gottshall, KR., Moore, RJ., Hoffer, ME. : Vestibular Rehabilitation for Migraine-Associated Dizziness. International Tinnitus Journal. Vol. 11, No. 1. P. 81-88. 2005.

Wrisley DM, Whitney SL, Furman JM. Vestibular rehabilitation outcomes in patients with a history of migraine. Neurology Report.  Vol. 24, No. 5, pp. 178. 2000

Whitney S Wrisley D Brown K Furman J : Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with a history of migraine. Laryngoscope. Vol 110 pp : 1528-1534. 2000

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