Vestibular Migraine – Webinar

0:00 [Music]
0:07 okay to start I just want to um quickly
0:10 say that we are proudly supported by the
0:13 following sponsors on the screen without
0:16 their support and their contributions we
0:18 wouldn’t be able to hold all this
0:20 programming such as these educational
0:26 webinars and today um first I’m going to
0:30 introduce Migra Canada I will then
0:33 introduce our keynote speaker Dr
0:35 Elizabeth laru and she will have her
0:38 vestibular migraine presentation and
0:41 after that we’ll have our question and
0:43 answer session part of the evening so
0:47 migraine candada who we are we are a
0:50 national nonprofit federally registered
0:53 charity supporting all Canadians living
0:55 with migraine and headache disorders our
0:57 mission is to improve the lives of
0:59 Canadians with migraine and other
1:00 headache disorders through advocacy
1:02 awareness education research and support
1:05 our five pillars um watch out for more
1:10 the our final uh 2023 webinar which will
1:14 be December 4th on it’s going to be on
1:17 the topic of migraine in children and te
1:19 teens our vestibular migraine webinar is
1:21 tonight and if you haven’t already most
1:24 of you probably are a part of our
1:26 community but you can join any time to
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1:32 events uh check out our advocacy page
1:36 where we have form letter templates and
1:39 other great resources to advocate for
1:42 better care and
1:44 coverage and you can also check out our
1:47 resource Library um available in both
1:50 both French and English these are two
1:52 page um resources on what migraine is
1:55 and different ways to treat
1:58 migraine
2:00 uh so before we begin we do need to make
2:02 it clear that this webinar provides
2:04 information and not medical advice
2:07 please note that the information
2:08 presented and discussed might not apply
2:10 to your own medical situation and always
2:13 discuss Medical Treatments with your own
2:14 health care provider who knows your
2:16 medical
2:18 history so Dr Elizabeth laru is our
2:21 keynote speaker tonight we’re very happy
2:23 that she’s joining us again um she is a
2:26 neurologist and headache specialist
2:28 currently practicing at the Brunswick
2:30 Medical Center Glen neuro and she is a
2:33 faculty lecturer for McGill’s neurology
2:35 department Dr laru completed her
2:37 neurology training at University of
2:39 Montreal and her headach Fellowship in
2:41 Paris France she directed the headache
2:44 Clinic of sura Hospital de University de
2:48 Montreal between 2010 and 2016 followed
2:52 by The Champ multidisciplinary Program
2:54 of the University of Calgary from 2017
2:57 to 2019 Dr laru is p as president of the
3:00 Canadian Headache Society the founder of
3:02 Migrant Quebec and founder of chair and
3:05 chair of migraine Canada Dr laru is a
3:08 well-known speaker for all audiences
3:10 interested in learning about headache
3:11 medicine and science she’s passionate
3:14 about education and advocacy for
3:15 headache disorders and her particular
3:17 interests include multidisciplinary and
3:20 holistic approaches the impact of
3:22 migraine in the workplace vestibular
3:24 migraine and cluster
3:27 headache and with that I’m going to turn
3:29 turn it over to Dr laru for her
3:33 presentation so uh thank you everyone
3:36 for attending this webinar welcome uh
3:40 it’s a it’s an evening in November I’m
3:43 sure you’re all busy and also thank you
3:46 for joining us tonight I want to thank
3:48 you also for your support of migraine
3:50 Canada and your feedback to us and also
3:54 sharing and talking about this because
3:56 as the chair of migraine Canada I really
3:58 want this organization to grow I started
4:01 it to serve people with migraine and to
4:04 uh break migraine stigma so uh I really
4:07 hope that we are helping you uh or the
4:10 people that you care about um in any way
4:13 that we can and we’re growing we’re
4:16 learning so uh thank you for feedback
4:18 sharing and being part of our community
4:22 so tonight tonight we talk about
4:24 vestibular migraine the image in the
4:27 background is a beautiful Lake I am a
4:30 fan of canoe camping and those are still
4:33 waters you know no storm no instability
4:37 no travel sickness ahead and so that’s
4:40 what we all wish for this nice quietness
4:44 but vestibular migraine is anything but
4:47 that and so I think it’s very important
4:50 that we talk about it tonight so I’ll
4:53 see if I can move now my
4:55 slides I do present uh my disclosure
4:58 information this is what I show when I
5:00 present to Scientific audiences because
5:03 I do receive an anaria from the for
5:06 mostly the pharmaceutical industry as a
5:08 speaker consultant or board
5:12 member everything is off label for
5:14 vestibular migraine so any comment I
5:16 will make on treatments or
5:18 medications uh here is entirely my my
5:22 opinion and hopefully supported by
5:25 evidence okay so I will start by saying
5:29 that my interest in vestibular migraine
5:32 and vestibular problems in general is
5:34 because I have personally experienced a
5:37 lot of it and uh I will disclose this
5:41 with you tonight that I had laberintitis
5:44 as a kid I remember lying in bed with
5:47 severe vertigo and vomiting for actually
5:49 close to two weeks um I also had severe
5:53 travel sickness as a kid throwing up on
5:56 cars um I had an episode of bppv V which
6:00 uh I will talk about a bit later just a
6:03 few years past uh I I do live with
6:06 episodic Migraine with and also without
6:09 Aura uh I I have a v visual intolerance
6:13 up to this day meaning for example that
6:16 I cannot watch movies that are shot you
6:18 know with instability and action zones
6:21 and sometimes I watch a screen and I
6:24 look around and everybody seems to be
6:25 enjoying themselves but I just cannot
6:28 look at all those moving images and this
6:31 is something I can see that I’m a bit
6:33 abnormal because everybody else seems to
6:35 be okay except me um I had two attacks
6:39 of severe vertigo with nagus so kind of
6:42 shaky movement of the eyes and vomiting
6:45 without headache that I think are
6:47 probably vestibular migraine but as you
6:50 will see do not completely fit the
6:52 criteria for vestibular migraine and I
6:55 also had an attack of migraine two years
6:57 ago after a day of
7:00 kayaking where I worked a lot with my
7:02 shoulders and the next day I woke up
7:04 with a you know a bad a bad headache
7:07 with neck pain shoulder pain and severe
7:09 dizziness that I kind of thought was
7:11 linked to my neck and to My overall um
7:14 migraine story so I’m telling you this
7:17 because when I I meet patients with
7:19 vestibular problems whatever the
7:20 diagnosis is I tell them that they do
7:23 not have to convince me that those
7:26 symptoms exist um so they do not have to
7:29 to um to convince me how disabling those
7:33 sensations of all kinds vertigo
7:36 vestibular intolerance visual
7:38 intolerance uh can be and so I share
7:41 that with you so you know that I really
7:43 care about those symptoms and those
7:45 problems whatever the diagnosis
7:47 is the other thing that I will to start
7:50 with um I want to start with is that
7:52 there are no simple answers in this
7:55 field I do go on different conferences I
7:59 attend congresses I am part of the
8:02 special interest group of the American
8:03 Headache Society on vestibular migraine
8:05 and
8:06 disorders and there there’s still a lot
8:09 that is in discussion even among experts
8:13 so it is normal that some doctors don’t
8:16 know about those things that some
8:18 doctors May disagree about those things
8:21 and that you might feel a little bit
8:23 confused about all of this because it is
8:26 not set in stone there’s so some degree
8:29 of uncertainty and and um definitions
8:33 that are tentative that might be
8:35 consensus from experts at present time
8:38 but not something that will always
8:40 remain in that state and that’s
8:42 something that is always a bit uh we
8:44 think that medicine is just like you
8:46 know there’s white one truth um and we
8:49 wish it would be the case but in this
8:52 field in particular there is a lot of
8:54 questions that are still open but I will
8:56 say that there’s more and more research
8:59 more and more Publications about it and
9:01 more and more presence in conferences
9:04 and scientific meetings of vestibular
9:06 migraine which was not the case 10 years
9:09 ago when I started to get interested
9:11 into
9:12 it so what we like cover during the
9:15 following uh talk we’ll talk about
9:18 anatomy and the meaning of the word
9:21 vestibular we’ll talk about the symptoms
9:24 uh we’ll talk about a few diseases that
9:27 can cause vestibular symptoms and may
9:29 coexist with migraine we will Define of
9:33 course vestibular migraine and then
9:35 illustrate different scenarios that
9:38 might uh lead to symptoms and then talk
9:41 about some tests and very practical
9:43 comments about different treatments I
9:46 will also make a little note about pppd
9:50 so persistent postural perceptual
9:52 dizziness a diagnosis that may coexist
9:55 with numerous vestibular issues so let’s
9:59 get
10:01 started so what does vestibular mean
10:06 right so vestibular relates to the
10:09 vestibular organs in our inner ear and
10:14 you can see here inside the uh the ear
10:16 there are two sets of organs there is
10:19 the ca the ca looks like a little snail
10:23 and this is the organ for hearing and
10:25 I’m not going to talk about it tonight
10:28 but what you see on the right side with
10:31 all what we call the semicircular canals
10:33 that are little tubes filled with
10:36 liquids that uh ensure our sense of
10:43 posture um are so the the semicircular
10:46 canals are the canals for our balance
10:49 and you can see that nature is
10:50 beautifully done because they are
10:53 oriented kind of 90 degrees apart in all
10:56 directions and they tell our our brain
10:59 where our head is going depending on uh
11:04 how the liquid flows you know so this is
11:06 really a biom mechanic uh gravity
11:08 influence system that uh will relate to
11:12 our brain how our head is moving in
11:15 Direction and also in speed so is it
11:19 rotating in that direction very fast or
11:21 just bending in the front very slowly
11:24 for example and it does that through
11:28 quite a complicated system and I will
11:30 not go go into great depth about this
11:34 but I want to show you how much we know
11:36 about the system in what we call the
11:40 different receptor organs right so we
11:42 have those tiny tiny little cells with
11:45 little fine hairs that are moving in the
11:48 liquid and then the movement of the air
11:51 the hairs are transmitted in electricity
11:55 in the nerve fiber isn’t that magical so
11:58 depending how how we move our head then
12:01 our those little hairs will feel and
12:05 then transmit into an electrical signal
12:09 that then will be put together by the
12:11 brain and then transferred to your
12:13 Consciousness to tell you information so
12:17 this is something that we we know and we
12:20 understand but we cannot necessarily see
12:22 in that degree of detail in a person
12:24 this is more from Anatomy but when we uh
12:27 we see a living human being we cannot of
12:30 course examine this in this degree of
12:34 detail and then once we have the
12:36 electric signal have to be transferred
12:38 to the
12:39 brain and uh interpret it and they then
12:42 interact with a lot of other things for
12:44 example what we see with our eyes what
12:47 we feel with our feet and what we feel
12:49 of of course also with our neck um so
12:52 there’s a lot of things kind of talking
12:54 together and everything has to align so
12:57 we have a bit of a sense of POS position
12:59 in the air so here is Illustrated in
13:02 this image that to uh to uh stand stand
13:06 stand stable and to feel stable when we
13:09 walk around for example well then we
13:12 have to use our ears our eyes our neck
13:14 but also all our spinal cord down to our
13:17 feet and legs because our legs are also
13:19 constantly telling us where we are all
13:22 of this is modulated by other organs and
13:26 I’m not going to go into great depth
13:28 about those neurological terms but for
13:32 example the cerebellum is one part of
13:34 the brain that will modulate all our
13:36 movements for precision and coordination
13:39 and it also plays a role into our gate
13:41 and our standing state so there’s a lot
13:45 of different organs that act that that
13:47 interact with the vestibular system so
13:52 um and next so this is a bit more detail
13:55 about this the vestibular system will
13:58 will uh play many roles because this
14:01 information about the position of our
14:03 head then serves different function for
14:06 example well it’s very important to uh
14:09 decide where our eyes are directed
14:12 depending on Our intention if I want to
14:14 catch something that’s moving or if I
14:16 want to study or to read if I want to
14:19 drive every time that we use our eyes
14:22 the Vesti system is an action because it
14:25 will help our eyes to focus on the
14:27 target and this can depend a lot on you
14:31 know what is moving where we’re focusing
14:34 far near Etc so the eyes are something
14:38 the balance we talked about the spatial
14:40 orientation you know where we are
14:43 globally in 3D at every time and then
14:46 the autonomic part autonomic Parts talks
14:49 about what Will mediate for example our
14:52 blood pressure our heart rate all kinds
14:55 of other functions in our body so our
14:59 vestibular system is interacting at
15:02 every moment with all of those systems
15:04 and you can see how this will relate to
15:07 the symptoms that we will describe in a
15:11 moment sometimes you will hear a lot
15:13 about neurologist or ENT talking about
15:17 peripheral versus Central and this is
15:20 something that we use all the time in
15:23 neurology and I think we can use a bit
15:25 of a computer analogy so the brain
15:28 Central
15:29 is like the computer it’s where
15:31 everything is put together interpreted
15:34 and analyzed so this is what we mean by
15:37 Central um and so This concerns
15:40 everything apart from the actual
15:43 peripheral organ so you could see that
15:45 peripheral is like whatever is plugged
15:48 into your computer a printer maybe a fax
15:51 machine maybe a scanner uh maybe some
15:55 other video game so all the organs that
15:59 are plugged into the system like the
16:01 peripheral vestibular organs are what we
16:04 call peripheral the minute that it
16:07 enters the brain then we call it Central
16:11 and in the central there are many
16:12 different bits and bites and programs if
16:14 you wish of the computer so when we see
16:18 a person with vestibular symptoms and
16:20 I’ll get that in a minut to that in a
16:22 moment we want to to try to understand
16:25 if they are from the peripheral system
16:29 or if they are more Central so for
16:32 example anyway so when we talk about
16:36 peripheral vestibular system the
16:38 symptoms are usually the assault very
16:41 clear rotatory vertigo a spinning
16:44 rotation something that that is spinning
16:47 and turning that is what happens when
16:49 the two peripheral organs are not in
16:52 full balance then when we go more
16:55 centrally then it can become a little
16:57 bit more difficult to to describe for
17:00 example thinking about those eye
17:02 connections having difficulty focusing
17:05 the vision uh sensitivity to moving
17:08 things like I was describing me in the
17:10 movie theater uh different patterns for
17:13 example and then there’s all this
17:15 question about the
17:16 sensitivity of someone walking so that’s
17:19 the connection with the cerebellum so
17:21 feeling unstable swaying feeling pushed
17:24 all of this uh is not directly
17:27 peripheral it’s not only the vestibular
17:29 system it’s the vestibular system in its
17:32 re relationships with other
17:35 systems okay then vestibular Sensations
17:39 let’s say the the the vertigo the sway
17:41 they may come with other symptoms but
17:45 these symptoms are not always caused by
17:47 vestibular issues so for example if you
17:51 have a lot of a vertigo then it will
17:55 activate strong reactions for example
17:57 the Str stress response okay you will
17:59 feel faint sweaty your heart will rise
18:03 we talked about this autonomic reaction
18:05 like adrenaline reaction stress response
18:08 this can be extremely disabling very
18:11 powerful but you can feel those things
18:14 even if you don’t have a vestibular
18:16 symptoms there’s a ton of other reasons
18:19 why you might feel like this nausea and
18:22 vomiting come a lot with vestibular
18:25 reactions but they can come with other
18:27 things for example just
18:28 plain Migraine with no vestibular
18:31 symptoms and then the vestibular issues
18:33 can also come with brain fog difficulty
18:37 to focus difficulty walking and all of
18:40 this can also occur without any
18:43 vestibular dysfunction and then of
18:45 course feeling like this will raise
18:48 anxiety and anxiety will increase the
18:51 vestibular sensation because anxiety
18:54 usually just is a dimmer on our
18:56 Sensations and if you are are very
18:58 anxious everything’s will be heightened
19:02 more powerful you will feel everything
19:04 bigger than it is uh whether it is an
19:06 emotion an expectation or a bodily
19:11 sensation so this those vestibular
19:13 Sensations are accompanied by other
19:16 responses that can be also quite
19:18 disabling but sometimes we might feel
19:21 all of those symptoms with no vestibular
19:23 issue whatsoever but then people might
19:26 feel that they are dizzy because they
19:28 feel like that but they have no
19:29 vestibular issue so feeling dizzy when I
19:34 was in med school I remember distinctly
19:37 it’s one of the things that is the most
19:39 difficult to question when you meet a
19:40 person a patient it’s one of the most
19:43 difficult symptom to describe for a
19:45 person there’s actually research showing
19:49 that people like will change their
19:50 description over time so for example if
19:53 you take a same patient in the emergency
19:55 with a complaint of dizziness well the
19:58 resident can come and take a very good
20:01 history and saying yes it was a spinning
20:04 rotatory vertigo and then the staff
20:06 neurologists come and the person nope
20:09 all the history finally changes and this
20:11 is very common so there are different
20:13 types of so-called dizziness the vertigo
20:16 that is spinning the disequilibrium
20:18 which is feeling kind of wobbly and
20:20 off-balance lihe headedness it’s kind of
20:23 woozy brain fog maybe this disconnection
20:26 and then this kind of autonomic feeling
20:28 that I mentioned feeling faint feeling
20:31 maybe sweaty or you’re going to lose
20:34 Consciousness and it’s okay not to be
20:36 sure because as I told you all those
20:38 symptoms come together and sometimes you
20:40 can have everything or you can have just
20:43 part of it and it can change over time
20:45 as well so you will see sometimes that
20:48 doctors might be a bit frustrated that
20:50 they don’t understand what you mean and
20:53 even if you try your best another thing
20:55 that you will see when you meet doctors
20:57 especially in the emergency department
20:59 is that they will try to push you in one
21:02 category they will tell you is it
21:04 spinning is it rotating because they
21:07 would like to understand if it’s
21:09 peripheral or Central right they try to
21:12 make it clear but sometimes it is not
21:15 clear that’s just the hard truth with
21:17 this
21:18 system all right now in the next four
21:21 slides I will present to you some other
21:23 diseases that will cause vestibular
21:26 symptoms and I swear I will get to V
21:28 migraine but I think we need to talk
21:31 about other diseases first and you will
21:33 see why the first is Miner’s disease so
21:36 Minier disease is a disorder of the uh
21:40 the whole vestibular system and also the
21:42 clear system so the auditory system as
21:45 you can see on the image below it is a
21:48 problem where all those canals that are
21:50 filled with liquid well the cavity
21:53 becomes somehow distended we call that
21:56 Hy drops right so it’s it’s like it’s
21:58 it’s too swollen it’s under pressure
22:01 like those little canals they’re very
22:03 sensitive and all of this leads to um
22:07 loss of hearing violent attacks of
22:10 rotatory vertigo usually with vomiting
22:13 that can last usually more than 30
22:15 minutes can be hours and it evolves over
22:18 years and sometimes people will
22:20 completely lose their audition on one
22:22 side so this is not an easy disease to
22:26 diagnose it will take an ENT to Do It um
22:29 but it is this is a very serious
22:31 condition though now we have more and
22:33 more treatments for
22:35 it bppv that I mentioned as well is a
22:39 disorder that’s completely different
22:41 it’s not many year’s disease and this
22:43 causes so it’s a problem of um a
22:45 displacement of the little I’ll call
22:48 them the little crystals because people
22:50 understand that very well we call them
22:52 in Medicus aonia so those are the little
22:56 rocks like we that are in floating in
22:58 the liquid and then they go in the wrong
23:01 place it’s like they are going to push
23:03 on those little hairs that we talked
23:04 about and they will send very wrong
23:07 signals of where your head is so when
23:10 you will for example turn your head in a
23:13 certain position typically in your bed
23:15 in a certain side then everything will
23:18 start to spin until the little crystals
23:22 are kind of SP like quieted down and
23:25 then you feel okay until you move your
23:27 head again and then it’s going to speed
23:29 spin spin again for a few minutes this
23:33 doesn’t come with usually attacks that
23:36 last hours or any hearing loss um and it
23:39 can be diagnosed now very well in
23:41 vestibular physio or by a doctor by
23:44 different maneuvers of the head and then
23:46 it can be also treated by maneuvers of
23:49 the head in the vast majority of times
23:52 so that’s why we call it benign because
23:55 usually it’s not a something that leads
23:57 to disability or long-term issues um and
24:01 Parx is small because it kind of starts
24:03 and stops and positional then we have
24:07 laberintitis laberintitis is something
24:10 quite elusive um roughly it is a viral
24:13 inflammation of the ear and it is like
24:16 any virus like the one I have right now
24:19 it comes and goes and it starts like a
24:22 bit suddenly people will have sometimes
24:24 hearing loss a lot of dizziness a lot of
24:26 vertigo nausea vomiting sometimes pain
24:29 in the ear as well and then it may last
24:32 a few days a few weeks it will resolve
24:34 there is actually no final diagnostic
24:37 test but if you do testing you will find
24:41 that both organs are not the same one is
24:44 actually not functioning right so this
24:46 is something that can be diagnosed but
24:48 it takes a bit of special testing which
24:51 they do not have in the emergency
24:53 department so I will say a lot of people
24:56 with vestibular mind MRA are thought to
24:58 have an episode of laberintitis because
25:01 they went to an emerge and that’s what
25:03 the ER people will diagnose when they
25:06 have excluded other things right they
25:08 will say oh it’s a laberintitis because
25:11 you know that’s the most common thing
25:13 probably in the emergency
25:16 setting and then the last thing that can
25:18 cause vertigo and dizziness but not the
25:21 least is stroke but of course stroke
25:24 it’s something very sudden it it occurs
25:26 usually one one time and that’s it and
25:29 it comes with other problems usually
25:31 it’s not only being dizzy it will be
25:33 with double vision a different things
25:36 for example numbness swallowing
25:38 difficulties I want to be very careful
25:41 here because stroke first is a serious
25:44 condition and I don’t want to make you
25:46 feel like there’s a unique picture of
25:48 what we call a brain stem stroke because
25:50 it’s a very complex things even
25:53 neurology uh residents struggle to learn
25:55 about brain stem stroke so so my whole
25:58 point here is that if you never had a
26:01 severe episode of dizziness or vertigo
26:03 in your life and you have one it’s okay
26:05 to go to the emergency department and to
26:08 be worked up for it in case you know it
26:10 may be it could be a stroke so I want to
26:12 be very prudent here about this one so
26:15 why did I present all of those diseases
26:17 and I haven’t still said a word about
26:19 vestibular migraine it’s because
26:21 migraine is actually comorbid it comes
26:24 it fares along all of those things so
26:28 people with migraine have more chance of
26:30 having bppv more risk I should say more
26:34 risk of having
26:35 Mur um they have uh I don’t think that
26:38 they have more risk of having
26:39 laberintitis they have a bit more risk
26:41 of having stroke though usually not
26:43 brain stem stroke um they have also more
26:46 risk of having motion sickness because
26:48 motion sickness is like this sensitivity
26:51 to vular perception and uh all of this
26:54 is two to three to five times more
26:57 frequent
26:58 so that means that like many other
27:02 problems of the brain um the migrainous
27:05 brain can be triggered influenced by
27:09 other diseases and that’s true for the
27:12 sinuses that’s true for the neck that’s
27:15 true for the mental health issues that’s
27:18 true for the TMG like the jaw problems
27:21 broism know people having grinding
27:24 issues all of this I call this the
27:26 pingpong of the brain so the migraine
27:29 brain will just react to whatever you
27:32 throw at it right so if you throw sleep
27:35 apnea at it well there’s going to be
27:37 more migraine and more symptoms right so
27:40 that’s true as well for any vestibular
27:42 issues so that means that if you have
27:45 you live with migraine and then you
27:47 develop Miner’s disease well of course
27:50 if you start having Miner’s disease you
27:52 might start having more migraine because
27:55 you’re going to have those attacks maybe
27:57 some stress related to it lack of sleep
28:00 vomiting
28:01 dehydration so there’s this influence of
28:04 vestibular diseases triggering migraine
28:07 migraine attacks so it might be that if
28:10 you live with migraine and you have
28:12 vestibular issues you do not have
28:14 vestibular migraine you might have
28:17 another diagnosis that has to be
28:19 diagnosed by a proper person may that be
28:21 an ENT or neurologist and treated
28:25 accordingly it might also mean that if
28:28 you have bppv and you live with migraine
28:31 well maybe the pppv will be a little bit
28:34 more intense and you will not adapt to
28:37 it because people will migraine do not
28:39 habituate very well to sensory stuff
28:42 right they they see they see more
28:45 intensely they cannot turn down you know
28:47 the level of the sounds of the light
28:50 their brain is just our brain I mean I
28:53 have my brain is just not wired that way
28:56 and that’s true also for vestibular
28:58 problems so for example when I had my
29:01 bppv I knew it was bppv I diagnosed
29:04 myself and I treated myself in my living
29:07 room um but then I was not completely
29:11 symptom free in between episodes because
29:14 I always felt a little bit dizzy even
29:16 after after this ratory phase because my
29:19 migous brain was just you know and I was
29:21 already sensitive so all of this took
29:24 more time to resolve um than it would
29:26 have someone without
29:29 migraine so the migraine brain becomes
29:32 sensitized and does not habituate
29:34 because either we have a lower threshold
29:37 so we perceive very mild Sensations or
29:40 there’s a lack of breakes inhibition so
29:42 we have an inability to ignore or
29:45 downplay whatever Sensations that life
29:47 strows at us and in that sense migraine
29:51 can lead to increase and persistent
29:53 vestibular Sensations caused by another
29:55 disease so now we come to the core of
29:58 things can migraine itself without any
30:02 other things cause vestibular
30:05 symptoms the answer is yes it can
30:09 there’s a lot of different causes of
30:12 different systems and different
30:14 pathophysiology hypothesis that can
30:17 explain why a person with migraine could
30:20 have a similar Sensations with no other
30:24 condition at all and um here I want to
30:29 invite you to think like a neurologist
30:32 which is we think by Zone by stage by
30:35 floor if you wish so we can imagine at
30:40 least five different things five
30:43 different parts of the brain that might
30:45 be involved in vestibular migraine from
30:47 the cortex so this is the outer part of
30:50 the brain to the thalamus which is a bit
30:52 of a regulating Center to the nuclei to
30:56 the cerebell
30:57 to the organs and then we can think it a
31:00 different way we could say maybe it’s a
31:02 matter of neurotransmitter so you know a
31:05 chemistry way is it serotonin is it
31:08 dopamine is it
31:09 acetycholine we can talk about it until
31:12 tomorrow morning okay so there are a lot
31:15 of ways linking the vestibular system
31:18 with the whole brain and all of those
31:21 have also actually been supported by
31:24 different research pieces for for
31:27 example showing abnormal things going on
31:30 in the cortex in the thalamus another
31:33 hypothesis you know could a vestibular
31:36 sensation be a Nora so maybe you know
31:40 maybe some people with vestibular
31:41 migraine have auras that are vestibular
31:45 so there’s a lot of potential reasons
31:48 and a lot of potential connections and
31:50 just for fun
31:53 prepare those are more connections just
31:56 showing
31:57 all the links between the pain systems
32:00 of migraine and the vestibular system so
32:04 there’s no end of potential links
32:07 between the vestibular ws and the
32:10 migraine
32:11 pathophysiology so and believe me a lot
32:14 of doctors don’t know about all of this
32:16 because just nobody told them it was not
32:19 part of their training and it’s just
32:21 damn complicated in theory there are
32:24 many brain mechanisms that could lead to
32:26 VES symptoms and migraine but the big
32:29 problem is there is no way to check that
32:33 in practice yet okay I to this day have
32:37 zero way there’s first there’s no
32:40 biomarker for migraine meaning that
32:42 there is no kind of official test that I
32:45 can run on someone in my clinic in
32:48 research centers and other thing um to
32:51 prove that they have migraine there’s no
32:53 way so and we have no way to study the
32:56 vestibular system
32:57 like just clinically in our in our
32:59 practice so you can imagine that having
33:02 headache that’s very common and then
33:04 disiness that’s also very common uh and
33:07 very difficult to question well they’re
33:10 both very very common symptoms and this
33:12 is partly why doctors are reluctant to
33:15 link migraine and dizziness as a
33:17 diagnosis
33:19 historically but what are the criteria
33:22 so here we are okay there’s been a lot
33:26 of different terms use um for
33:30 migraines for what we call now
33:32 vestibular migraine there was something
33:34 called M migraine Associated so migraine
33:37 Associated related disiness migraine
33:40 vestibulopathy migraine is vertigo all
33:43 of those terms have been used in the
33:45 past now we use V tuber migraine so it
33:48 takes
33:49 roughly uh at least five episodes and
33:53 you need to have a history of migraine
33:55 and I’ll make one point you you have to
33:58 have headaches okay you cannot have no
34:00 history of headache and have aular
34:02 migraine this is not a thing then the
34:05 vestibular symptoms have to be there the
34:08 last lasting between five minutes and 72
34:12 hours and then a half of those episodes
34:15 are supposed to be associated with at
34:18 least one of three migrainous features
34:22 you so a headache with different
34:24 characteristics of migraine photo and
34:26 pho phobia or visual Aura so this is
34:31 where it’s getting a bit tricky because
34:34 in theory you could have you know for
34:37 example 50% of episodes with just visual
34:41 Aura and you could call this a
34:43 vestibular migraine but that’s not the
34:45 most common scenario so just remember
34:48 those criteria are working criteria
34:51 they’re not final and they’re absolutely
34:53 by no means something that I expect to
34:55 see set and stone for for the next
34:57 whatever
34:58 years but this is what we work with at
35:00 present time in addition to the symptoms
35:03 that I just showed there there’s a lot
35:05 of other things that people who fit
35:07 those criteria also present so they will
35:11 have for example attacks of untriggered
35:13 vertigo they can have provoked vertigo
35:16 even by you know you look at something
35:18 that moves triggers you moving the head
35:21 triggers you um moving your body
35:25 triggers you you can have tinitus which
35:27 is something extremely common in the
35:30 population and even more in people with
35:32 migraine you can have a feeling of
35:35 having a full ear you can have the
35:37 famous oopsa or shaky eyes which is kind
35:40 of when someone has the nagus which is a
35:44 a term we use in neurology when the eyes
35:45 are beating with a rhythmic way
35:48 unsteadiness lightheadedness Alice and
35:51 Wonderland is something a bit more aware
35:53 that is a distortion of size for example
35:56 or even color
35:57 so that’s something that’s
35:59 associated and those symptoms are very
36:02 disabling and I don’t need to tell you
36:04 this if you live with vestibular
36:05 migraine so this is an example where in
36:08 a daily life or vestibular Sy system in
36:12 a busy environment like a metro station
36:15 everything’s moving you are moving
36:17 people are moving their sounds their
36:19 lights and then it might overrun your
36:22 brain your your sensory analysis system
36:26 and then all of this might become
36:27 overwhelming and you might feel
36:31 dizzy anxiety and other symptoms also
36:34 accompany vestibular migraine anxiety is
36:38 extremely high and like I’ve explained
36:40 to you it’s no surprise because those
36:42 Sensations can be extremely disruptive
36:45 depression is high insomnia is very
36:47 common brain fog phobias so having
36:51 phobias for example of busy places
36:54 agoraphobia and also what we call
36:56 functional syndrome which I will not go
36:59 uh in detail to at present time but this
37:02 is really something that comes with the
37:05 different types of mental health issues
37:07 all right so I want to make a comment
37:10 here if if those of you maybe who do not
37:12 know this guy this is Dr glaucon fleen
37:16 this is a fake name for a guy who is
37:19 doing videos about medicine if if you
37:22 want to look him up he’s hilarious for
37:24 us doctors if you are in heare you will
37:27 understand those jokes so on the left
37:29 you have the neurologist with
37:32 interesting hair style and and glasses
37:35 on the other side you have the ENT
37:37 you’re looking you know we make fun of
37:38 Surgeons to to be a little bit uh you
37:41 know like like this what why and to be
37:43 very kind of physical people but not
37:46 necessarily intellectual like
37:47 neurologists anyway so sometimes the
37:51 ent’s will refer to neurology people who
37:54 have so-called chronic dizziness but
37:56 they have no history of headache no
38:00 diagnosis of migraine and then they will
38:02 say oh the patient is dizzy I cannot
38:05 find anything in the peripheral organ
38:07 let’s send to neurology for vestibular
38:10 migraine as I’ve shown you to have a
38:13 diagnosis of vestibular migraine you
38:15 need to have a diagnosis of migraine how
38:19 much migraine is not too clear you know
38:22 what if you had a few episodes in your
38:24 teens and never again is that’s a
38:26 efficient um so the typical history of
38:29 vestibular migraine I’ll show in a few
38:31 moments but just to be clear that
38:33 there’s a gazillion reasons why someone
38:35 might feel dizzy with no headache and
38:38 that is not vular
38:41 migraine so there’s many scenarios those
38:44 hyas very are very long to take so when
38:47 I meet a person with a complaint of
38:49 headaches and
38:51 disiness then I have to go over the full
38:54 history of migraine with a simp symptoms
38:56 their duration their frequency whatever
38:59 happened the tests the treatments and
39:01 then I have to do a history of the
39:03 vestibular complaints and as you’ve seen
39:05 there are many different types of
39:07 symptoms so to have every symptom the
39:10 duration the frequency what was done the
39:13 testing and eventually the treatments
39:16 and then do they associate right so are
39:19 they coming together are they linked or
39:23 is it someone who has a history of
39:25 migraine and then they Miner’s disease
39:28 right so I always look at impact and
39:30 disability impact on mental health
39:33 anxiety hypervigilance avoidance and
39:36 then of course all the treatments so
39:39 those are very long stories to take and
39:41 once again sometimes you know doctors do
39:45 not have the the time or interest or
39:47 training to perform those complex
39:49 histories and it leads to sometimes a
39:52 bit of just this disregarding or saying
39:55 oh vular migraine is not a thing it is a
39:58 thing it is a diagnosis it’s just it’s a
40:00 bit
40:01 complicated so here is a typical history
40:05 that I see in my office so it is usually
40:08 so it can be a man of course but let’s
40:10 say there’s more women in her 40s
40:13 there’s something with vestibular
40:15 symptoms and the 40s right is it the
40:18 premenopause or is it hormonal or is it
40:20 having kids and parents and taking care
40:23 of everybody I don’t know but I see a
40:25 lot of V symptoms start starting in the
40:28 40s so she has a history of migraine at
40:32 32 she had a so-called laberintitis so
40:34 she had three weeks of vertigo at gained
40:37 its stability then she recovered but
40:40 then she remained sensitive to movement
40:42 but people who have laberintitis
40:44 sometimes do remain sensitive to
40:46 movements that’s documented at 38
40:49 migraine frequency increased that
40:52 happens at 40 she had another
40:55 laberintitis that was maybe a bit
40:57 shorter and since then she has episodes
41:00 of dizziness sometimes with migraine
41:03 sometimes without like we’ve seen
41:05 doesn’t have to be every episode linked
41:07 with the migraine or with headache um
41:09 lasting one or two days and overall she
41:13 has some episode 20 days per month so
41:16 sometimes the migraine with or without
41:18 the vertigo and the dizziness and in
41:20 between episode she’s always very
41:22 sensitive to things that are moving fast
41:25 and every visual stimuli she’s cautious
41:28 with driving she has stop dancing
41:29 lessons her neck is very tense and the
41:32 osteopath says that she has cervical
41:34 disiness that I would be would I would
41:37 say would be a quite typical history of
41:40 vestibular migraine now don’t get me
41:43 wrong vular migraine can start at any
41:45 age it can start very young can start
41:47 older it can come in all types of
41:50 frequency durations and flavors but
41:52 that’s something I see a lot in my
41:55 office so to illustrate this in a bit
41:58 more synthetic or schematic way so I I
42:02 like to have two lines right like I said
42:05 the line of the migraine history and
42:07 then the line of the vestibular history
42:10 and now I added here little starts you
42:12 know this laberintitis is it because you
42:15 had migraine then you had a laberintitis
42:18 an inflammation of your ear and since
42:21 then this kind of sensitized major
42:23 vestibular symptom or your vestibular
42:25 system
42:26 more sensitive and then you develop
42:29 Migraine with vestibular symptom that’s
42:32 a theory that’s around and that might be
42:34 very true for some people then the other
42:37 thing that I sprinkled there is TBI
42:39 traumatic brain injury so we know people
42:41 with concussion will develop vestibular
42:44 symptoms it’s part of the concussion
42:46 symptoms feeling dizzy brain fog and
42:49 then all the rest that I mentioned so
42:52 that sometimes will trigger also
42:54 vestibular symptoms that might C coexist
42:57 with migraine and then people might
42:59 evolve from having occasional attacks to
43:03 having those kind of chronic symptoms
43:05 chronic headache chronic uh photophobia
43:09 chronic dizziness vestibular intolerance
43:12 and always being in this kind of super
43:14 sensitive state that we are familiar
43:18 with u a few words about the Nick what
43:21 about the Nick so a lot of people
43:25 believe in cervical genic dizziness um
43:28 and cervical genic dizziness the idea is
43:30 because our neck and as I’ve shown you
43:32 the neck also tells us where our head is
43:35 you know at any time so the idea is that
43:38 there are some nerves in the neck that
43:40 will tell us where our brain is and that
43:43 might actually lead us to feeling woozy
43:46 unstable and we know that’s possible
43:48 because when we block those nerves in
43:50 the neck my patients when I do nerve
43:52 blocks sometimes they will say wo I feel
43:54 a little bit dizzy so so that makes
43:57 sense that the neck could come could
43:59 cause dizziness but the current thinking
44:02 of the scientific Community the Baran
44:05 society which is the leading
44:06 organization on all of this is that
44:09 cervical genic disiness is over
44:11 diagnosed and even scientifically
44:13 uncertain so there’s a lot of website
44:17 out there from osteopath chiropractor
44:21 claiming that they can cure you know
44:23 cervicogenic disiness I think it it’s
44:26 it’s AB it’s absolutely okay to do
44:28 everything to take care of your neck um
44:31 but it’s very normal that feeling dizzy
44:33 will also cause neck pain and neck
44:36 tension so sometimes it’s very difficult
44:38 to call the chicken or the egg so at the
44:41 end of the day my point on cervical
44:44 genic dizziness is I basically never
44:46 diagnose it except in very rare
44:49 condition I just put it in the whole
44:51 Melting Pot I try to stabilize the neck
44:54 of my patients the best I can with with
44:56 different techniques and the cause the
44:58 original cause is very rarely the neck
45:01 it’s part of the problem but it’s rarely
45:03 the
45:05 cause all right so now that we have
45:08 discussed quite a bit of stuff so the
45:10 definition the anatomy the science you
45:13 know other diagnosis I will tell you at
45:15 this moment you probably know more than
45:18 quite a many doctors uh who don’t have
45:21 not no interest in vular
45:23 migraine so now practice what does that
45:27 mean for you as a potential patient
45:29 living with
45:30 this so first if you live with this set
45:34 of symptoms of migraine with dizziness
45:37 well first you should see an ENT and get
45:39 appropriate testing mostly to exclude
45:43 other disorders okay so there are many
45:46 tests that can be done not necessarily
45:49 to diagnose vestibular migraine but to
45:52 exclude other things so vng is called
45:55 the video nagog so that’s where they put
45:58 those funky goggles on you and then they
46:01 record your eye movements um with
46:03 suppressing your fixation means that if
46:06 you don’t see in front of you because of
46:07 the goggles then the eyes will kind of
46:10 go around a bit more freely and they can
46:13 uh analyze the eye movements very uh
46:16 precisely that’s a very important test
46:18 to test the vestibular system caloric
46:21 testing is uh looking at the reflexes of
46:24 the ears with cold and hot
46:26 so hot water cold water it’s not
46:29 particularly funny because it will it
46:31 will cause vertigo and dizziness so for
46:34 people with vestibular migraine it’s
46:36 usually not a fun test so is the test
46:39 that you see at the at the at the below
46:42 part of the image testing more about the
46:44 postural reflexes um and the the kind of
46:48 the standing function of the vestibular
46:50 system vemps are vestibular evoked
46:54 myogenic potential this is is more to
46:56 check about the relationship between the
46:58 neck and the vestibular system and then
47:01 the audiogram to test hearing so none of
47:04 that can be done by a good ENT lab but
47:09 there is no specific testing for VM and
47:11 40% of people will have fully normal
47:16 vestibular testing despite meeting the
47:18 clinical criteria 60% will have some
47:24 abnormality right it can be a bit of
47:26 decreased hearing it can be a little bit
47:29 of abnormal eye movements uh so there
47:32 are Central and peripheral so I’m not
47:35 going to go into detail about what is
47:37 what but there’s a long list of
47:40 different things we can look on these
47:41 tests and we can find some abnormalities
47:45 they may actually deteriorate over time
47:47 in people with VM um but this is not
47:50 part of the diagnostic criteria because
47:53 it’s not specific enough
47:56 two so keep an adapted diary this is
48:00 maybe not a super good example because
48:02 it’s not detailed enough the diary we
48:05 use in the clinic where I work I work
48:08 with an an ENT expert in min’s disease
48:11 and we have built a very detailed diary
48:14 we don’t do that forever where people
48:16 will record you know everything the
48:19 headache the photophobia theophobia the
48:21 nausea the hearing aspect the short
48:25 dizziness the long dizziness the intense
48:27 vertigo the and so people can just map
48:30 all of this and then we see what type of
48:33 episode coals you know together versus
48:36 separate and that helps us understanding
48:40 what is going on with a particular
48:43 patient so even I mean having a headache
48:46 diary I’m sure some of you have done
48:48 them it takes time it’s a lot of detail
48:51 if you have vestibular migraine it’s
48:53 even more detail but it’s very
48:57 important three a lot of people want to
49:00 know about vestibular physio should I do
49:03 it right so what is vestibular physio
49:07 vestibular physio is designed usually
49:10 for people who have a peripheral problem
49:13 right we think that vestibular migraine
49:17 is mostly a central problem and that
49:21 people with vestibular migraine do not
49:24 habituate right so they have difficulty
49:27 adapting their brain have difficulty
49:29 adapting so usually when we use
49:32 vestibular physio it’s because one organ
49:35 is weaker than the other then there is
49:37 an imbalance and we train the brain to
49:40 manage this imbalance right so this is
49:45 very good if you have a problem with an
49:48 organ but if your problem is the
49:51 habituation it’s longer and more
49:54 difficult to train and to use vestibular
49:56 physio to improve so there are studies
49:59 showing that vestibular physio is good
50:01 for vestibular migraine but it takes
50:03 more effort more time and of course the
50:07 exercises which is mostly like looking
50:09 and challenging your brain to adapt are
50:13 going to be difficult and disagreeable
50:15 so sometimes um I will say that it’s
50:19 better uh investing in anxiety
50:22 management because at the end of the
50:25 today a lot of the disability coming
50:27 from this can be mitigated if someone
50:31 decreases their reaction to the
50:33 vestibular symptoms and like I told you
50:36 I’ve had those those symptoms I know
50:38 what they are so sometimes adding the
50:41 the layering like the icing on the cake
50:44 of anxiety
50:45 hyperventilation Panic then everything
50:48 is worse so sometimes just learning
50:51 simple breathing techniques a managing
50:54 avoidance managing triggers that’s very
50:57 difficult but it can be done so
51:00 sometimes I do refer more my patients
51:02 actually to Psycho therapy CBT uh
51:05 breathing exercises or different types
51:08 of therapists then to the vestibular
51:10 physio depending sometimes they do both
51:12 actually so that’s very important the
51:16 problem is that a lot of my patients
51:17 with VM well because nobody believed
51:20 them for so long and they don’t want to
51:22 be told they’re crazy they don’t take
51:25 very well the idea of seeing a therapist
51:28 so I tell them that the idea here is
51:30 that they’re not crazy but they will see
51:33 the therapist not to talk about their
51:35 parents or their childhoods or or so on
51:38 it’s really about key techniques to
51:41 manage the autonomic search the
51:43 autonomic reaction of having those very
51:46 disruptive
51:48 feelings all right in that line of
51:50 thought what is Triple PD so triple PD
51:55 is persistent postural perceptual
51:59 dizziness this is a relatively new thing
52:03 it does not exist like 10 years ago
52:05 nobody was talking about even five years
52:07 ago it was not that common now everybody
52:10 talks about it so this is what we call a
52:13 functional neurological disorder um I
52:17 will not go into detail about the
52:19 definition of fnd I do invite you to go
52:23 on neurosymptoms.org to read about about
52:25 it but roughly triple PD is when there
52:30 is an interplay between the vestibular
52:32 system but a lot of the anxiety system
52:36 and sometimes there is actually a
52:37 vestibular episode something happened
52:39 maybe you had labyrinthitis for example
52:42 very easy or maybe
52:44 bppv and then your your brain reacts by
52:48 producing a lot of
52:50 hypervigilance and a lot of avoidance
52:53 and by watching a lot and then producing
52:57 like a a constant feeling of of
53:00 instability that is never ending that is
53:03 always there that fluctuates and people
53:07 develop sometimes a bit of a like weird
53:09 way of standing with oscillations
53:11 walking and and everything is is is
53:15 constant and disabling but at the end of
53:18 the day the key issue is not vestibular
53:20 it’s more into different let’s say some
53:25 times anxiety traits but also sometimes
53:27 just the way your brain is caught in a
53:29 bad loop it’s caught in a loop where
53:32 those symptoms are just there and their
53:34 brain is keeping their keeping them
53:36 going and going without you wanting it
53:39 of course right so this is what a
53:41 functional neurological disorder is and
53:44 triple PD isn’t that family of systems
53:47 you can see here that there’s usually a
53:49 precipitant then different personality
53:52 traits or different uh pre-existing
53:54 anxiety traits and then sometimes there
53:57 is also a context so there’s sometimes a
53:59 context and then all of these loops and
54:01 turns and turns can be very disabling
54:04 and it has to be addressed attacks may
54:08 be very difficult to treat you know this
54:10 probably already if you live with this
54:13 um migraine attacks should be treated as
54:15 usual with nides STP Tans gens and so
54:19 on the problem I see in my clinic are
54:21 the violent vertigo attacks those are
54:25 tough and I’ll tell you there is no
54:29 let’s say there’s no magic recipes for
54:32 those I’m still shopping for it I’m
54:34 asking around you know when I go to
54:35 conferences and so on so sometimes I
54:38 give my patients injectable tryp tons
54:41 nasal sprays like zooming for example
54:44 gravel
54:45 suppositories because they are not you
54:47 know absorbed by um ingestion um can be
54:50 Life Savers there’s also all the other
54:53 suppositories but sometimes they’re
54:54 backward for example
54:57 metoclopramide procar parazine or stemy
55:00 so anything that is not taken by mouth
55:03 obviously can go faster and hopefully
55:06 help you Zofran if you haven’t had
55:09 Zofran for nausea and you live with
55:11 migraine this is an amazing thing very
55:13 well tolerated and often very effective
55:18 antihistamines so histamine plays a role
55:21 and and those of you who have travel
55:22 sickness you know that we use
55:24 anti-histamine prevented benad reactin
55:27 sometimes can make you a bit sleepy
55:29 which can be a relief and then yes I
55:32 told you about anxiety so breathing is
55:35 great but sometimes it’s not you know
55:36 working so sometimes I will use my I
55:39 will give my patients some benzo
55:41 diazines like Atavan or
55:43 Kazan um but there is a risk of
55:47 dependence addiction and this should be
55:50 discussed carefully with your healthc
55:53 care providers um there are different
55:56 you know neuromodulation devices that
55:58 might be of interest like gamore or
56:00 sephy and then the whole gamut of you
56:03 know migraine treatments that of any
56:05 relief you know headache hat and cold
56:07 and warm and and and smells or you know
56:10 mint rollers and so on but those attacks
56:13 are tough and even in my practice I
56:15 struggle to treat
56:17 them prevention okay so here you might
56:21 wonder why there are all those little
56:25 circles um they are buttons I call them
56:28 chemical buttons so when I present um
56:32 vestibular migraine to my patients I
56:35 explained to them that the vestibular
56:37 system is a bit like a it’s like a
56:39 control panel a very complicated control
56:42 panel because you see here this little
56:44 neuron so this is a a neuron of the
56:47 vestibular system and it’s very well
56:50 connected it has lots of friends um so
56:54 it is really connected to every
56:57 neurotransmitter you can dream of
56:59 there’s a reason why so many medications
57:02 can give dizziness as a side effect
57:05 right so it means that virtually
57:09 anything can modulate the vestibular
57:11 system which is a good and a bad thing
57:14 so there’s a lot of preventive so the
57:17 good news is the bad news is it’s trial
57:19 and error there’s no way that I can
57:21 predict or anybody can predict what will
57:24 work for you
57:25 the good news is I have seen successes
57:28 with one every one of those options and
57:31 good successes so I tell my patients it
57:34 is a long road of trial and error and
57:38 it’s even more complicated than with
57:40 migraine normal because you have to kind
57:42 of check the migraine but also the
57:47 vestibular symptoms and if you have a
57:50 vestibular disorder in addition to it
57:52 like for example Miner disease it’s even
57:54 more more complicated so but it can be
57:58 done and it can work so Verapamil for
58:01 example amitryptiline or trolene beta
58:04 blockers prolol at the pyramid
58:08 venine fenine is an old thing that has a
58:11 lot of side effects that come with it
58:13 but sometimes it’s used for migraine
58:15 with aura and also vestibular Migraine
58:17 with success lotr gen is usually not
58:20 used for migraine sometimes we use it
58:23 for vestibular symptoms
58:25 Botox can work cgrp antibodies can work
58:29 um and things like Gabapentin or prabin
58:32 so that would be um Gabapentin is
58:35 Neurontin and lria um so all of this can
58:40 work and no doctor can predict which one
58:43 is going to be good for you but it worth
58:45 trying and you have to carefully look at
58:47 your symptoms and see if they
58:50 work so additional resources um I have
58:55 two of them I think some of you might
58:57 know already The Dizzy cook.com there’s
58:59 a lot of recipes in there which I’m not
59:02 too sure are going to be the key to your
59:04 migraine management they’re I’m sure
59:05 they’re delicious but there are there is
59:08 actually a vestibular migraine guide
59:10 there with a lot of comments about
59:12 vestibular migraine because this uh
59:15 person has vestibular migraine and then
59:17 the vertigo doctor.com is an interesting
59:20 website where they have therapy so they
59:23 have I mentioned about vestibular physio
59:26 so vestibular Groove fit is a program to
59:30 manage better vestibular migraine I
59:32 cannot advertise for it because I I
59:34 don’t know exactly what’s in there but
59:37 I’ve heard some good comments about it
59:39 and it’s definitely worth investigating
59:41 so those are good resources for you guys
59:44 and um I think that uh if I can give you
59:48 a bit of a a note of Hope is that there
59:51 are things that can help you out there
59:53 and as with all my patients I recommend
59:55 a holistic approach uh incorporating
59:58 everything from exercise breathing
01:00:02 medications uh optimal management so my
01:00:06 my conclusion well I hope I shown you
01:00:08 that the vestibular system which is
01:00:10 bugging us obviously and I I I’m I’m
01:00:14 definitely suffering from my vular
01:00:16 system but it is fascinating definitions
01:00:19 are evolving vestibular migraine is
01:00:23 disabling I think we should think in
01:00:25 terms of networks and instead of names I
01:00:28 mean we need names and diagnosis but um
01:00:31 uh I think just keep in mind the
01:00:33 complexity of those systems and move
01:00:35 away from a kind of a All or Nothing
01:00:38 black and white it is this or it is that
01:00:40 usually it is a mix of many things
01:00:43 vestibular physio may not be the key it
01:00:45 might be worth it though anxiety
01:00:47 management extremely important uh if you
01:00:50 live with VM trial and error is still
01:00:52 the best approach there is growing
01:00:54 evidence for Botox and cgrp blade I
01:00:57 haven’t shown you studies but there are
01:00:59 studies and triple PD is probably a part
01:01:03 of the problem for at least some people
01:01:05 with vestibular migraine and it can be
01:01:07 addressed also by proper
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