Vestibular Rehabilitation Therapy, or VRT is a form of physical therapy aimed at reducing symptoms of dizziness, vertigo, and lightheadedness in those who have vestibular dysfunction. Those with Vestibular Migraine, a very common vestibular diagnosis, are some of the many people who benefit from VRT.
While Migraine Strong writes about the latest in migraine treatments, this is not medical advice. We are patient educators and all information you read should be discussed with your doctor.
What is Vestibular Migraine?
Migraine is a genetically induced hypersensitivity to a stimulus within the central nervous system causing a myriad of symptoms – in this case dizziness, imbalances and vertigo. When we hear about migraine in the general population, many people think “really bad headache”, but we know that this is absolutely not the case. Especially because in Vestibular Migraine, you do not even need a headache for an accurate diagnosis.
It is estimated that about 1% of the US population has Vestibular Migraine, which is typically undiagnosed or misdiagnosed (1).
These symptoms include:
- Photosensitivity (light sensitivity)
- Phonosensitivity (sound sensitivity)
- Neck pain (cervicalgia)
- Motion sensitivity
- Panic and anxiety
- Altered cognition
- Spatial disorientation
- Feeling “foggy”
- Heavy headedness
- So many more!
The neuron primed for migraine in this case is, or is related to, the Trigeminal Nerve and potentially the Vestibulocochlear nerve, or Cranial Nerves V and VIII. This nerve controls balance, equilibrium, spatial awareness, and head position. If you have a migraine here, you will feel off balance, dizzy, or even like you are walking on marshmallows.
The official diagnostic criteria for Vestibular Migraine are: (2)
- At least 5 episodes of vestibular symptoms of moderate or severe intensity lasting 5 minutes to 72 hours
- Current or previous history of migraine with or without aura according to the ICHD classification
- At least ONE or more of the following migraine features with at least 50% of vestibular episodes:
- Headache with at least 2 of the following characteristics (one-sided location, pulsating quality, moderate or severe pain intensity); -and/or-
- photophobia or phonophobia; -and/or-
- Visual aura
- Not better accounted for by another vestibular or ICHD diagnosis
All healthcare providers have access to this criteria, so they can access it. You can help by showing it to them if this sounds like you and you’re trying to receive a diagnosis. Then your physical therapy for vertigo and other symptoms can begin.
What is Vestibular Rehabilitation Therapy?
Vestibular Rehabilitation Therapy is the habituation and adaptation of your vestibular system to irritating stimuli. Simply put, this means this means your brain slowly gets stronger so you can tolerate stimuli and activities symptom free. Because there are so many reasons you can be dizzy, from Vestibular Migraine to Acoustic Neuroma, Vestibular Rehabilitation Therapy is actually incredibly common. I see patients with almost every dizzy-diagnosis!
The most common reason Vestibular Therapists see patients is for Benign Paroxysmal Positional Vertigo (BPPV). This is a mechanical dysfunction of the inner ear, when otoconia (ear crystals) fall out of the organ where they belong into the semicircular canals. The “quick” fix for this is the Epley Maneuver, and usually clears the vertigo symptoms in 1-3 visits. The topic of BPPV is often of interest to people with vestibular migraine and deserves its own article. Stay tuned as I will write about it in greater detail in the near future.
But what about dizziness that is not caused by BPPV? Those with Vestibular Migraine, Meniere’s Disease, Secondary Endolymphatic Hydrops, Trigeminal Nerve Decompression, or general lightheadedness for an unknown reason are ALL excellent candidates for vestibular rehabilitation therapy.
Who benefits from VRT?
If you have a diagnosis that causes dizziness, especially Vestibular Migraine, you would absolutely benefit from Vestibular Rehab. Your Vestibular Physical Therapist will come up with a customized treatment plan to treat your specific symptoms. No two Migraine Brains are the same, and therefore no two treatment plans will be exactly the same.
You should expect to treat the leftover symptoms of Vestibular Migraine with VRT, not necessarily the migraine itself – more on this below!
What should You expect from Vestibular Rehabilitation Therapy?
Treatment of dizziness through exercise looks a lot like training your body for anything. I frequently compare Vestibular Rehabilitation Therapy to heavy weight lifting. No, you shouldn’t necessarily expect to start lifting heavy weights during physical therapy for vestibular migraine, but you should expect to do something a little bit difficult, and mildly dizzying, every time you do your exercises.
At your first appointment, you should expect to do a lot of talking. Your vestibular physical therapist should discuss your lifestyle, your habits, your migraine triggers, what makes you dizzy, what makes you feel better when you’re having an attack, what you have tried so far, and your personal goals. You should talk about anxiety, depression, and emotional struggles you may have with your Vestibular Migraine and all other symptoms relating to it. Even if you feel like it’s unrelated, it could be good to mention.
Vestibular Migraine Exercises
You may not even get prescribed exercises at your first visit – if you don’t, that is okay, everyone’s treatment is different. We often need to take things very slowly. You and your physical therapist should work at your pace as a team. They may push you a little bit, but it shouldn’t ever be too much. When you are prescribed vestibular migraine exercises, expect to do them daily and to meet with your PT weekly, or every other week.
The 5/5 Rule for VRT
You should expect to be a little bit dizzy after each exercise, but not for more than 5 minutes. I find myself referring to the 5/5 rule more times a day than I can count. It is SO important to stimulate your symptoms, but only in a way you can always bring back to baseline!
This brings me back to the heavy weight lifting analogy. If you started going to the gym, and had a goal to do a Bicep curl with 50 pounds, that’s not where you would start. You might start at 10 pounds, and slowly work your way up toward 50. You are probably going to get a little bit sore when you go to the gym. However, you wouldn’t push yourself to get so sore you can’t recover, right? Vestibular Rehabilitation Therapy for is identical. You need to push yourself into your symptoms a little bit, but you should always be able to bring your symptoms back down to baseline.
This is the 5/5 rule. Never increasing dizziness more than 5 points over your baseline, and never at that level of dizziness for more than 5 minutes.
What happens if you are already dizzy before you start your exercises for the day? That is okay – that’s your baseline for the day. Let’s pretend that number is a 2/10 (where 0/10 is no dizziness at all). 2 is where you start, you should avoid raising your dizziness level 5 above the two. And each time you stop an exercise, bring that back down to a 2 before your next repetition or set of exercises.
Another incredibly important factor in physical therapy for vestibular migraine is that you are actually moving your head for exercises. Your vestibular system loves movement – it is in charge of keeping you upright and tracking where your head is in space, so the more your head moves the more quickly it will adapt (as long as you stick to the 5/5 rule!).
Communicating with your physical therapist
If generally exercising is a trigger for you, be sure to tell your PT on your first day. VRT exercises are not usually high intensity exercises, so they should not trigger a migraine if you’re sensitive to exercise. They will make you mildly dizzy for a short time, though – this is normal.
The follow up sessions should be you and your PT the entire session. It is best to avoid being handed off to someone outside of your primary PT. Although everyone means well, vestibular exercises need to be closely managed, so sticking with your main physical therapist for the whole session is recommended. Expect that your PT will find ways to make you dizzy, and then let you rest – remember, it’s supposed to make you a little bit symptomatic, but then you should be allowed to recover back to baseline!
What should you look for in a Vestibular Therapist?
Physical therapists, and some occupational therapists, are the most qualified providers to treat symptoms of dizziness and vertigo through exercise. However, like most medical professionals, only some physical therapists are qualified to treat dizziness & vestibular disorders. Because Vestibular Migraine is deeply complex and ever changing, it is important that you find a PT who will spend time with you one on one, who will work with you for at least the next few months, and truly understands how the vestibular system works.
Of course, each Vestibular PT will be different, we all have our quirks, but the hallmarks of a great Vestibular Physical Therapists are:
- Someone who is willing to listen.
- A person who takes the time to educate you on WHY you feel like this, and how the Vestibular System functions.
- Someone who specializes in vestibular therapy
- A person who never minimizes your symptoms.
- Someone who pushes you a little bit, while helping you understand why too much VRT can be too much for your brain.
- A person you actually get along with! You are going to be spending a lot of time with your Vestibular Therapist, likely more than any of your other healthcare providers. If you can, try and find someone you get along with, it will help make the process more enjoyable!
When should I start Vestibular Rehabilitation Therapy?
Vestibular Rehabilitation Therapy is meant to treat the symptoms that remain after your vertigo spell, not to treat the migraine itself. Vestibular Migraine should be treated with a team of healthcare professionals. You will likely have a neurologist, Otolaryngologist/ENT, maybe a Neuro-ophthalmologist, a vestibular physical therapist, and maybe more. Each provider has a specific role to play in your healthcare. Finding a treatment plan that treats the migraine, not just the symptoms, is important. This is frequently the first step. Being diagnosed with Vestibular Migraine is often overwhelming, and Vestibular Rehabilitation Therapy is usually not the first thing to be prescribed.
Each person’s treatment is different, I cannot stress this enough. Sometimes Vestibular Migraine patients with new diagnoses start VRT immediately, and do very well. However this is not always the case. Some Vestibular Migraine patients are having attacks so frequently that delaying Vestibular Rehabilitation Therapy may be wise.
My general rule:
The general rule I use is that the patient should be able to manage their migraines on most days before starting physical therapy for vertigo.
Remember, Vestibular Rehabilitation Therapy treats the leftover symptoms. The lingering symptoms that occur as a result of your migraine: motion sensitivity, imbalance, lightheadedness. So, if you are having very chronic flares, it might not be the right time for you to begin VRT. If you aren’t sure, please find a Vestibular Rehabilitation Therapist for a consultation. They will be more than happy to help you figure out if you would be a good fit, or if you should wait.
Tips for what to do if the room is spinning
Vertigo can be very sudden and incredibly scary. If you have Vestibular Migraine, there is a high chance you’ve had true, room spinning, vertigo. This spinning sensation is caused by nystagmus, or involuntary eye movement. For as long as your eyes are moving left and right, due to Vestibuloocular dysfunction, you are going to feel the sensation. This can be caused by Benign Paroxysmal Positional Vertigo, Vestibular Migraine, or both.
My general rule about BPPV versus Vestibular Migraine
My general rule is that if spinning only happens with change of position, it is probably BPPV. If it happens when you’re standing still, and haven’t changed your head movement then it is likely Vestibular Migraine.
When spinning happens and you’re already laying down, stay there until it stops. If it is BPPV, it will stop after about 15 seconds, even if it feels like forever. If it’s Vestibular Migraine, it may last longer; stay on your bed and safe until the spell passes. Usually nystagmus doesn’t last for more than a few minutes. Standing up could cause you to fall, so I always recommend staying put.
If this happens and you’re standing at the kitchen sink, or walking through your home, try to grab a wall or something sturdy, and lower yourself to the floor. Wait for the symptoms to pass and initiate your rescue plan – if you have a drug, practice, or other remedy for migraine symptoms between you and your physician, use it to your advantage.
Tips for when vertigo happens in an unsafe place
It is possible that vertigo may begin in a different, scarier place. Like if you’re driving or walking across the street. If you are driving, do your best to focus on the horizon to keep your eyes still, slow down and pull over the car. The same thing applies if this happens in the street – focus your eyes on something you’re walking toward, find a building or something to hold onto, and either sit on the ground or stand until you feel better.
I know the thought that this can happen in a dangerous place can be a source of anxiety in itself. But often Migraineurs know their symptoms and can predict when a migraine is coming – use this knowledge to your advantage and always have a safety plan.
Many people have found these tips to to help with anxiety associated with migraine to be valuable.
Can you feel better after long-term dizziness?
Here’s the short answer: YES!
Just like any long term injury, illness, or condition, healing long term injuries or dizziness is a longer process than short term. However, it is absolutely possible. Chronic dizziness diagnoses do not have to mean that you are going to feel that way forever.
It may take a little longer, but Vestibular Rehabilitation Therapy is very effective when performed correctly with a trained Vestibular Therapist.
Vestibular migraine exercises I can do while I wait for an appointment with a Vestibular Specialist.
There are so many vestibular migraine exercises that will help your dizziness when you get to Vestibular Rehabilitation Therapy, however I don’t recommend you try any without the consultation of a Vestibular specialist. Performing exercises incorrectly can make you feel worse. However, there are a few things that I find make people feel better and aren’t so risky!
Grounding is great for relaxation and deep breathing exercises. It helps your body feel multiple surfaces be still at once, which can increase your sensory load, and remind your brain that you are not moving. Tell yourself that you are still, in a safe and calm environment, and have permission to feel good.
Box breathing is a way of breathing. Imagine a box, each side has 4 counts. Breathe into your diaphragm (stomach) for 4 counts, hold for 4, exhale for 4, and hold for 4. Repeat for as long as you would like until you feel some stillness and relaxation.
Balance exercises are so important. Our vestibular systems are one of three systems responsible for balance. These three systems work together to keep you upright. You can challenge this system by practicing your balance on uneven surfaces, or with your eyes closed. Test your balance with the MCTSIB test if you have another person around to help you. Additionally, single leg stance, tandem stance, and other balance exercises are great!
A little about Dr. Madison Oak:
Hi, my name is Dr. Madison Oak and I am a Vestibular Physical Therapist, and the founder of The Vertigo Doctor. I graduated with my Doctor of Physical Therapy degree from the University of Wisconsin – Madison, and immediately started working as a Vestibular PT in New York City. Throughout Physical Therapy school, I always knew I wanted to be in the realm of neurological physical therapy, but it wasn’t until one of my clinical rotations that I became fascinated with the vestibular system.
Vestibular symptoms and disorders are difficult to describe, complicated to diagnose, and lacking in understandable patient and clinician resources. Working as a team with all of my clients to find the right treatment is my favorite part of being a physical therapist. Each person’s symptoms are different, and therefore each person’s treatment is different. I am here to help you by providing understandable content, a path to finding a provider, and much more.
As miserable as dizziness can feel, it is incredibly treatable through vestibular rehabilitation and other medical avenues. Vestibular Rehabilitation is incredibly powerful, and I am here to help guide you toward the right resources and treatment to begin your journey to recovery.
Contacting Dr. Oak:
Check her out on Instagram
Explore her website TheVertigoDoctor
(1) Tepper, D. (2015, November 12). Migraine Associated Vertigo. Retrieved September 02, 2020, from https://americanmigrainefoundation.org/resource-library/migraine-associated-vertigo/
(2)Hilton, D. (2020, June 07). Migraine-Associated Vertigo (Vestibular Migraine). Retrieved September 03, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK507859/
(3)Roberts RA, Gans RE, Kastner AH. Differentiation of migrainous positional vertigo (MPV) from horizontal canal benign paroxysmal positional vertigo (HC-BPPV). Int J Audiol 2006;45: 224–26