Do you want to learn more about vertigo? Do you ever experience dizziness or have migraine attacks? In today's episode we talk about all of these things including natural remedies.

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Show Notes:

1. The importance of a holistic treatment plan for BPPV and migraines:

• Understand the key factors that contribute to BPPV, including blood pressure, vitamin D levels, and underlying vestibular conditions.

• Learn how a comprehensive treatment approach can include medication, supplements, diet, hydration, exercise, sleep, meditation, and support from healthcare providers.

2. Migraine as a spectrum disorder with distinct phases:

• Discover the different phases of migraine, including prodrome, aura, impact/headache, postdrome, and interictal phases.

• Explore the varying frequency and severity of migraines and the importance of staying informed about new treatment options.

3. The dizzy-anxious-dizzy cycle and the power of breathwork:

• Learn about the connection between dizziness, anxiety, and vertigo, and how they feed into each other.

• Explore the benefits of breathwork in regulating the nervous system, reducing anxiety, and managing dizziness.

4. Free Masterclass on managing dizziness and vertigo from home:

• Check out Dr. Oaks' free Masterclass, "Three Steps to Controlling Your Dizziness and Vertigo from Home," for an introduction to her treatment approach for patients with dizziness and vertigo symptoms.

Key Takeaways:

• A comprehensive treatment plan, including medication, lifestyle changes, and support, is crucial for managing BPPV and migraine.

• Migraine is a spectrum disorder with distinct phases, and breathwork can help break the dizzy-anxious-dizzy cycle.

• Dr. Oaks' free Masterclass offers valuable insights on managing dizziness and vertigo from the comfort of your home.

Transcript:

Hello, Hello, everyone, and welcome back to Better Than a Pill. Today, I am so excited to have Dr. Madison Oak as a guest. Dr. Oak is a physical therapist that specializes in treating vestibular migraine and chronic dizziness. So welcome, Madison. Thank you so much for being here today. Thank you so much for having me. I'm so excited to be here and talk about my very favorite thing, vestibular disorders. So thank you so much for having me on. You are welcome. Excellent.

In fact, I am going to let you explain a little bit about what a vestibular therapist is and a little bit about the type of work you do. Absolutely. So my name is Dr. Madison Oak. I am trained as a physical therapist. All physical therapists graduate school as a generalist, so we are able to treat hips and knees and backs and also vestibular disorders. Not all PT schools go heavily into the vestibular disorder realm, but where I went to school, University of Wisconsin, they did, and then I was lucky enough to have a couple of internships in it as well, at the very end of school. So I really have this solid foundation of vestibular disorders when I graduated, and then I kind of took it from there.

So a vestibular therapist is a person who treats dizziness disorders and issues that happen in your inner ear. So if you can imagine your ear or touch your outer ear, the part on the outside of your ear is just your outer ear, right? It's for hearing. You can see it. You can touch it. You can feel it. You can stick your finger in there even though you know you're not supposed to. And then you get your eardrum. Your eardrum or your tympanic membrane is what separates your outer ear from your middle ear. Your middle ear, if you look at a picture, kind of looks like Florida, if you, like, Google it. But basically it's just a Eustachian tube. And that tube at all times is closed. And then when you go on an airplane or you dive deep into a pool or you feel congested and you can't pop your ear, that's your Eustachian tube being stuck together with mucus. If you're sick or if you can pop it, it opens for a second. It regulates the amount of air in your middle ear, and then it closes again.

The last part you want to know about is then deep into your skull. So we have our outer ear, middle ear, and then into our skull, our inner ear. That part is the part that is our hearing organ. You learn about that part that looks like a snail in, like, high school biology class, and then they move on. They forget to tell you about your vestibular system, which is the three canals attached to the snail looking part, attached to your cochlea. And that part together makes up your inner ear. And that is what I treat that very tiny, tiny organ.

That is extremely helpful. Beautifully described. Thank you. Yeah, we don't really hear a lot about the vestibular part of our year. I know, that was very helpful. For me, it's like dizziness is such a common issue, and that's one of the reasons I have you here today, because I want to talk a little bit about that. And in my experience, the only form of dizziness that I have encountered is vertigo. And it's in the clients that I've worked with over the year, a lot of them have found have had problems with this, and I found it very individualized. And the one common trait that I happen to observe while working with people on Pilates or mat work is that about 90% of them need to have their head elevated slightly while on their back. So what is vertigo? Help break this down for us? Definitely.

So that's a really excellent question and a really excellent observation. So all vestibular disorders can cause some sort of dizziness. And dizziness is like an umbrella term. So dizziness can mean anything to lots of different people. That's why it's so important to describe your dizziness. And we're starting with dizziness and not vertigo for a very specific reason. So dizziness is this umbrella term. It can mean imbalance, vertigo, lightheaded, heavy headed. I know some people who are like, "I'm dizzy," and I say, "What does that mean?" And they say, "Well, I can't feel the floor." That is not the same as the room spinning around me. But people describe all of these different symptoms as dizzy.

So dizzy is this overarching terminology. If you want to know exactly what vertigo is, it has a very specific definition, and it is the incorrect perception that you or the room around you is moving, sliding, or spinning. So you could have external vertigo, which is probably what your clients are talking about, and I'll get to that in a second. Or you could have internal vertigo where you feel like, "I feel like I'm moving like this, even though when I look in the mirror or someone looks at me, I'm not moving." Those two are even different things, but they're both technically vertigo.

Now, the most common form of vertigo is something called BPPV, which is benign paroxysmal positional vertigo. Benign, not going to kill you. Paroxysmal meaning fast and spontaneous. Positional, in certain positions. And vertigo, meaning the room is spinning. Now, that kind of vertigo is the kind of vertigo where the tiny ear crystals in that little system I talked about before at the very beginning, there are two pieces, there are two parts of that system. One of them detects linear motion, and that's done by ear crystals. Basically, they're called otoliths. And then the other detects angular motion, and that goes into semicircular canals where fluid moves around.

Now, if those otoliths, those crystals, fall into the semicircular canals, your eyes are going to twitch when you move backward after you stop moving. So that goes into a lot of physiology of it that I could go down a rabbit hole of, but we won't have to go there today. But basically, these crystals fall out into your ear and you have an ear crystal problem. It's very easy to treat for the most part. Most people, if you have a client, if you're listening to this, have a client or a patient who's like every time they lay down, whether you're a dentist or Pilates teacher, your patient or client says the room spins. And so I just don't lay down anymore.

There are a lot of repercussions for never being able to lay flat – neck pain, back pain, avoidance behaviors, lots of stuff that can kind of negatively impact your quality of life for something that is very simple and straightforward to treat with something called a canalith repositioning maneuver. There are lots of different types of those, but that's the most common form of vertigo, and it's a mechanical issue. It's not a neurological problem. It's not from an infection or a virus or anything like that, and that is vertigo.

Now, other things can cause vertigo. Like what I treat, vestibular migraine can actually mimic BPPV, which gets a little convoluted there. And people tend to treat that with those maneuvers we talked about, like the athlete maneuver. And they're like, it's not going away because it's actually a neurological issue like vestibular migraines. So there's a lot to kind of break down and that's why seeing a specialist when you have dizziness or vertigo is so important.

Yeah, absolutely, I mean, there's so much involved there. And it's interesting what you just said because I've heard of the Eple maneuver, right, but I've never heard of the other maneuver before. Yeah, that's fascinating. And then it's like the root cause of the vertigo is interesting. So it's not always the vestibular system, it can be a neurological issue and so on, correct? Absolutely.

So first, the Epile maneuver is a type of canal at the repositioning maneuver. But there's lots of different ones. There's a samont, there's the barbecue roll, horizontal head. There's different things depending on different canals that can be affected, but they're all similar to the epilepsy and that. You have to put your head in weird different positions and your PT will roll you through them.

And then yeah, vertigo doesn't only come from that one issue, just like you're saying it can come from a neuritis. If it's short term, like one to four days, you might have room spitting vertigo. If you have hours and hours of room spinning vertigo, it could be from veneer's disease if you have quick spins during the day, but you're not in a certain position, that could be vestibular migraine. So there's lots of things that cause the room to spin and there's also lots of things that feel like I am spinning inside and so, just like you were saying, it's really important to kind of get to the reason that you have this vertigo. Because vertigo is never a diagnosis, it is only a symptom. So people go to the doctor, they say, I've been diagnosed with vertigo. It's not a diagnosis, it's just a symptom of something else that's happening.

Wow, so we have neurological vestibular, what other things have you seen cause vertigo? A lot of things can cause vertigo. They can be again, it can be a peripheral vestibular disorder, meaning it is in the inner ear itself. So that's Menir's disease, vestibular neuritis, BPPV, some kind of concussion can affect the peripheral system. Then you can have central vestibular disorders. So that is the rest of concussion if it didn't affect your peripheral vestibular system. Vestibular migraine is a central disorder. Stroke is something that can cause dizziness and vertigo, that's a central disorder. So all of these things are central or peripheral, but you can have something like cervicogenic dizziness, and that's not going to cause the room to spin. That should not be. But it can cause you to feel like you're doing this or like you have a bobblehead. And that could be some internal vertigo that's happening. So again, there's just tons and tons of reasons that it could happen.

Yes, so internal versus external. I mean, that's right. There a nugget for me. I didn't even realize that. And then what about so vertigo can come and it can go quickly through several different types of maneuvers, not just the upli in so many ways, but what about when it becomes chronic?

Yeah, so if we're talking about BPPV, that shouldn't be chronic, that's like one very distinct form of vertigo. It's a mechanical issue, should be treated with a maneuver, and then you should move on with your life. There is a 50% chance that it'll come back in the next few years. But again, return to your physical therapist, do the maneuver again. And it should go away if it's coming back like every week, every month, every few months. And you're like, I just definitely BPPV. Like, the test always comes back positive. I always go through the maneuver and it gets better. But then in a few months, you should check your vitamin D levels, your blood pressure, your bone density. So there's lots of things like that that you can check in on and say, are these things like normalized level to make sure my BPPV isn't coming back for that reason?

Now, if you have chronic dizziness, the thing we call chronic dizziness is persistent postural perceptual dizziness, and that's three PD or PPPD, triple PD, whatever you want to call it. Now, this kind of dizziness is a chronic subjective disorder. However, if you did get a special kind of brain scan, you can see brain changes because you're utilizing and not utilizing different parts of your brain due to avoidance techniques and different habituation techniques that you're like overusing your eyes and not using your vestibular system enough. And so the kind of three systems of balance your eyes, your ears and the way you feel the floor aren't working together. And that can cause some brain changes, basically. But there are specific diagnostic criteria. It's not a trash can diagnosis. I feel like a lot of people are like, well, my doctor just says I'm dizzy, so I have this it is caused by an underlying condition. So there is like a root of three PD. So the root of three PD can be anything from I had a panic attack and now I have three PD, to one of the more common causes, which I have vestibular migraine. And now in between migraine attacks, because vestibular migraine, migraine in general is a chronic disorder which whether or not you're having attacks you're living with all the time, and one in seven women has migraine disorder. Then migraine attacks are the acute form of migraine presentation, but it's always there. Then between attacks, you could be dizzy and you kind of have this consistent kind of up and down, I'm swaying, it wax and wanes. But it's always their type, dizziness, that is three PD, which can be on top of vestibular migraine or any other vestibular diagnosis.

I see. And so if somebody is triggered, for example, I had a client that was triggered by a neck massage to get dizziness, which she assumed was vertigo again, now, not knowing exactly what type, but how does that happen? So your neck muscles are in a certain place and they're like doing their happy thing or whatever, right? They're like, oh, my neck is so tight, I'm just going to go get a massage and see. So sometimes people with something called cervicogenic dizziness, which I treat it, it's not my specialty. I have some other friends who it is their specialty, and if I can't get it in a couple of sessions, I'm like, maybe we should refer you to other people, right? And I'm very big into referring to the right person. But people with cervicogenic dizziness, it's dizziness that's coming from your neck and the proprioceptors in your neck that aren't sending the right message. So let's say I turn my head to the right. My vestibular system on the right will fire more than my left, and it'll be an inhibition on the left, excitation on the right. When I look forward, it'll be like this again. And this is how it should go all day, every day if you're watching this on video, or more to the right when you look to the right, more to the left when you look to the left. Basically, in your vestibular system, your proprioceptive system, which is the way that your body interacts with itself internally and says, which way am I going? How extended or contracted is my elbow? Am I standing up? Am I sitting down? Can I feel the floor? Everything in that realm of where am I? In space? Is managed by little muscle spindles as well as your vestibular system. And those things should talk to each other.

Now, if you do have cervicogenic issues, it's coming from your neck, and it can be for a multitude of reasons. It could just not be talking to your vestibular system. Right. You could have had a Whiplash injury, and that Whiplash injury stretched those spindles out, and now they don't know where they are in space. 

You could be a person with a history of neck pain or a history of migraine, which is affecting your neck and causing neck pain. We do know that a very, very common symptom of migraine in general and vestibular migraine, of course, because vestibular migraine is a type of migraine disorder. All these things can cause neck pain. So then those people go get a massage, and then all of a sudden, those muscles are relaxed and stretched out, and then your head doesn't know where it is in space anymore. And that can cause dizziness because your head is like, oh, I'm Bobbly. I feel weird.

And instead of strengthening and stretching in those areas, which I do find to be more effective, especially for people with dizziness or any history of vestibular disorder, they just kind of get these massaged, and then they're like, oh, my God, I no longer know where I am in space. And I find my patients and clients with vestibular migraine actually tend to get much, much worse post massage. Not everyone, but most people, especially if the masseuse is not or the massage therapist is not familiar with vestibular disorders. Extremely informative.

If somebody experiences the dizziness after a massage, that can also become chronic. And this is what happened to a client of mine where it became chronic. Yeah. So it could become chronic for a few reasons, but similar to chronic pain, chronic dizziness works almost identically. And we're taught a lot about chronic pain in school, and I think we probably all know someone. My back always hurts, or my neck always hurts or whatever. Chronic dizziness is the same. It's a learned neuroplastic pain, or it's a learned neuroplastic dizziness.

So with low back pain, something maybe you went to the gym, you,And these learned patterns come from a lot of different places. It's more common in people with a history of trauma, history of anxiety, history of depression, and other mental illnesses and things like that. Just because of the way that your brain works, there's less serotonin and a dopamine. And I hate to say the word imbalance, but, like, out of the average bell curve, you could say right now, when you have back pain, this is something that typically we can kind of grasp easier because we either know someone with it or we've had it ourselves. And you can touch your back. You can feel your back. You can't feel your brain and dizziness, right?maybe it doesn't go away, and you're like, I just can never pick up my dog again. I can never go to the gym again. I can never do these things. If I just sit in this position and I turn really carefully and I don't move in, like the ways I used to move because that's going to hurt my back, then I just won't have back pain anymore. But then that inherently causes more back pain because the less you move, we know,  let's say, deadlifted, or you picked up your dog from the floor and you tweaked your back. You're like, oh, that kind of hurt, right? In a couple of days, the more pain you might have.

The exact same thing is happening with dizziness. So you go and get a massage. Then if you move your head a little bit, it's like, oh, my God, I get way dizzier. This is horrible. I can't stand this. I'm just going to do this forever. Then you do this. Then your muscles learn that this is normal, and then your vestibular system stops moving. And the less you move your vestibular system, the weaker it gets and the less adapted to movement it becomes. So you're like this, and you're like, if I just move like a robot for the rest of my life, I'll be fine. I won't be dizzy, right? But then your brain learns that every time you look to your dog or to your kid or your spouse or your friend, and you look to the side, right? Oh, God. And that whole dizziness cycle kicks in.

Dizziness and anxiety are also processed in the same parts of the brain. There's obviously lots of different parts these two things are processed in, but a lot of the things trigger the amygdala and that fear response back here go, oh, my God, this is horrible. I don't want to feel like this. I'm trying to protect you. And so these things just cycle on each other and cycle and cycle and cycle until you can break that fear response and you can start to strengthen your neck and tell your body that it's okay to move your neck and that you can actually relax your shoulders and relax your neck and do all these different things in order to kind of get yourself back to a place where you used to be, where you could move your neck.

You could turn in the grocery store. You could turn around fast and look at your dog if it was doing something weird or bad or whatever, right? So all of these systems in our body are meant to work a certain way. It's not meant to be like we're just moving like a robot or not moving at all, right? Where we turn in a block, we're supposed to have all of these joints in order to move in all of these directions. And the less we move them, the more fear and anxiety that come with that movement, the dizzier we will be.

That totally makes sense, especially when you correlate it to movement, because I see that all the time. We can't just stop moving. Let's just say that. Here's another question for you real quick. Somebody had chronic dizziness, like an example of my client, and then they sleep on a different pillow and it's gone. Have you seen that before?

I think that different things work for different people. Right. And if all of a sudden your neck is happy in this new place and the dizziness is gone, great. I also think that we give a lot of power to the placebo and I love it. I'm a huge fan of using that to our advantage. Right. This pillow is going to work for me. This thing is going to work for me. I don't care what it is. Could be laying on a red yoga mat instead of a green yoga mat. I don't care if it works for you, it works for you.

I'm not going to say there's special science behind special pillows because there's really not. Like whatever pillow is comfortable for you is the pillow you should use. Whatever mat on the floor you like is the one you should use. It's like running shoes. They say whatever shoes you go into the store and decide are comfortable are the best running shoes for your feet. And so it's the same thing for pillows. So if it goes away, more power to her. Happy it did. Right? Thank you. Yes.

One last question about a trigger. One more example is I've had a couple of clients that no longer get facials, a couple of women, because they have triggered vertigo. So, again, this is the kind of vertigo where I want to know what kind it is and were they laying back, probably, right? Were they probably not laying back at home because they know that's going to trigger vertigo. But they did. When they go to the facialist, you put your head back in the thing or whatever, right. That's not triggering the vertigo. The vertigo issue was there and you triggered the response.

So BPPV, you cannot physically cause BPPV to happen unless you get a head injury, like a concussion, for instance. You cannot cause them to fall out into your semicircular canals. So people like, I don't go to the dentist, I don't get my hair washed at the hair salon. I don't get a facial. I don't do XYZ because that requires me to lay back and that triggers my vertigo. But at home, I don't ever lay back. I sleep on three pillows and I do XYZ in order for my head to never be in this dependent position when in reality it was already there. They're floating in that canal. They're living in there, and you just don't ever trigger them into this position. You don't look up into cabinets. You don't do this with your head. And so if you are in that scenario and then you do go to the facialist and they have you lay back and it's like, oh my God, I'm spinning for 15 to 60 seconds. That is from BPPV that was lying dormant, and you triggered the response.

Wow. So in essence, it was there all along. And what you're saying is really, we need to work through and get those movements where we put our head back into our day, into our lives, for it to really be removed from our system. So, yeah, I mean, with BPPV specifically, again, that mechanical cause of dizziness that needs to be treated with the vestibular therapist, it's a very easy treatment. People are terrified of the treatment sometimes because it does require you to go into that position of spinning. So the first step of the Epley maneuver, for example, is actually the test to see if you have BPPV. So you lie back with your head in this position, and then your eyes are going to twitch in a certain direction, and your PT needs to look at the direction of the nystagmus and say, okay, it's going this way, it's going that way, and that's going to dictate the next head movement.

So you're in here and you're like, okay, my head is back to the left. My eyes are doing a left up-beating. Dystagmus great. I know it's in this canal. You wait until it's gone, plus another like 30 ish seconds. You go to the next position. It probably won't be in this position. Then you go to the next position and then you sit back up. So will it trigger that? Yes. Is it going to last forever? No. Is it going to make it better in like a minute and a half? So it's not there anymore at all? Also, yes. So it's a really positive treatment, and your therapist needs to explain to you exactly what they're doing the whole time. And also you always, of course, have the option to stop or not do it. I have had people deny the treatment before. They're like, I'm just going to move like this. Usually in a couple of months, they come back with neck pain, and then I say, okay, well, I can't treat that neck pain until we treat this because there's a lot of stuff we've got to do. Supine. So typically then they say, okay, now I'll get it treated, and then all of it tends to go away.

Yeah, that's very helpful real quick because I know you mentioned a lot of natural physical therapy type maneuvers for the vertigo. Is there any other anything else before we move on? Okay, yeah, so it depends on the type of dizziness you have. Right. Vertigo and dizziness, they're very vast. There are lots of different things that I could be. Now, my very favorite thing to talk about is movement, exercise. It will help everything and everyone gets mad at me and it's like, but movement makes me feel worse. But if you do it correctly, it won't make you feel worse for a long time, and long term, it will make you feel better.

So strength training is going to help reduce the likelihood of BPPV. It's going to help reduce the likelihood of migraine attacks and Meniere's disease attacks. It's going to help you recover from 3PD. We know people who exercise and move their body on a regular basis are less dizzy than those who do not. So it's a really great start. Right. Moving any way you can. I really recommend strength training and obviously walking. Everyone should be walking, right? So both of those things are really good.

Well, I love to hear that. The next one depends on the type of dizziness you have. Again. But most people with migraine, just all kinds of migraine disorders, right. Talk about migraine disorder being this chronic thing. The attacks are the acute presentation. People always say, I have migraines with an S on the end. We're trying to nix that language. I have a migraine disorder, I'm having a migraine attack. People with epilepsy don't have epilepsies. They have seizures. Right. We have a name for the attack. Even though they live with the chronic condition of epilepsy, they have a seizure when it's attack. It's the same thing with migraine.

So if you live with migraine, most people are prescribed magnesium, CoQ10, B2 which is riboflavin, and vitamin D, as well as some sort of omega fish oil, DHA EPA combo complex. It is quite a bit of magnesium, typically 400 to 800 milligrams per day between like glycinate or citrate or threonate, depending on how your stomach and stuff handles different things. Threonate can help with the brain fog. This is obviously not medical advice. I never talk about medical advice unless you are one on one in my clinic with me. But that is something to know that you should talk to your doctor about.

And you really should have a headache specialist if you have any sort of migraine disorder, you do not need head pain in order to get a migraine diagnosis. That's something else that's really important to understand and know, is that dizziness plus light sensitivity and sound sensitivity or dizziness plus a migraineous aura or something like that, all of those things can also add up to be enough for a migraine diagnosis. So that is something that's definitely interesting to know as well.

As far as BPPV, since these are like the two biggest things we're talking about today, going back to that mechanical kind, you really should keep your blood pressure in check, right? So making sure that's like another vital sign. Honestly, if you ask me, blood pressure is such an important one. So if you have high blood pressure, then that is something that will make it more likely for you to have constant or chronic BPPV attacks. If you have low vitamin D, that can also be more likely to have BPPV attacks. If you have an underlying vestibular condition, like a history of neuritis or vestibular migraine, you'll also have BPPV attacks more frequently. So that's all things to note and kind of taking a step back and looking at this comprehensively rather than, I just have this thing that I need to take care of, I'm going to take a medication.

I don't pill shame. I don't med shame. I think if your brain chemistry needs that medication in order to help with your migraine disorder, often more power to you. But usually it's not just one thing. It's usually not just a medication that's going to help. It's going to be medication for some people, plus supplements and diet and hydration and exercise and sleeping and meditating and doing yoga and breathing and getting support and asking your therapist for help and asking your family for help. And it's like this long list of things that we call the treatment pie.

And for everyone, it's going to look a little bit different, but it's going to need to be comprehensive and take quite a few providers, probably, if you have something like vestibular migraine. Wow, thank you for that. And there's so much power in what we can do through lifestyle changes, nutrition, movement is what you're saying. Yeah, that's great.

I know you kind of touched in on the migraine. And it's not migraines, it's migraine. I get that. That's a huge takeaway for me today in a migraine attack. And it's a migraine disorder, and that can also be individualized and just in my experience with clients that have had migraines, I'll have a client that has an occasional attack, I mean, once or twice a year. And then I'll have certain clients that are having them a lot and even have special glasses that they have to wear and just wanted to touch base on that a little bit. Yes.

So it is a spectrum disorder, meaning that some people might have a migraine once in their whole life and people might have them once a day. Migraine goes through distinct phases, so it starts with the prodrome phase, which can be one to two days before the attack. Prodrome could be anything from food cravings to changes in mood and irritability. It could be an increase in light sensitivity. It can be lots of different things. And if you Google like, migraine prodrome symptoms, there might be some you can relate to.

If you do have a migraine condition, then it's the aura. And not everyone has this. Not everyone has prodrome either, but most people do. About a third of people with migraine have aura, which should last around 45 minutes. You can have a prolonged aura, but that's something talk to your doctor about. Most people have, if they have aura last around 45 minutes. This can be a motor change. It could be seeing something in your vision, like spots or something flashing or like a pinwheel. It could be like you go limp on one side of your body. It can act like a stroke, but it's not a stroke. Some people, like I have this history of weird mini strokes, but typically it's actually not typically, but a lot of times it's migraine. It can be you can smell like burning toast or something like that, similar to people who have epilepsy or seizures. They tend to smell like different smells as well. So that's something to consider.

After the aura phase, you have the headache phase, which I like prefer to call the impact phase because most of my patients don't actually have head pain and they just get this really awful, like, vertigo, dizziness, imbalance, can't stand up from bed kind of feeling, which is different. And then you have postdrome and that can last up to a day or two. And that typically feels like a hangover for most people. Some people it feels like I just woke up from the best nap of my life and I have this whole new me. But for most people it feels like I'm hungover without the fun the night before. So that's what people tend to describe it.

And then the fifth phase, which I'm not so sure we call it a phase, but the fifth period is the interactal, meaning between attacks. Now, some people have a very distinct, long interictal phase, like your patient or your client who has I only have one attack a year that interactals everything else. Because remember, this is a chronic condition that lives in your brain always. There are no cures for but it can go into remission, into extended interactal phases. You may still be more sensitive to light or to smell, but you're not having an attack, right? And that's different. If you are having them back to back to back, you might skip over the interactal phase entirely and you might go from postrome back to prodrome like back to back. And people are kind of cycling like this and breaking that cycle can be difficult, but it is possible. And if you're a person who lives with acute or chronic migraine, I want you to know that there is hope, there are tons of options. And do not let any doctor, no matter what kind of migraine you have, tell you that you are out of options because that's just not the case. There's always more stuff coming out, there are always more options being discovered and your headache specialist really, really will be a big part of that team. There are only about a little less than 700 headache specialists in the whole entire country and there are so many people with migraines. So I know waitlist can be long but checking in with them can be super helpful.

Great. Thank you so much. This is so helpful. I want to say I have one last little question, just touching upon briefly. Do you ever use the power of breath work or breathing for any of these disorders?

Absolutely. So the dizzy, anxious, dizzy cycle is probably something that I see in every single one of my patients. And whether it's like dizzy, frustrated, dizzy, dizzy, scared, dizzy, dizzy, anxious, dizzy, whatever it is, these things play on each other. And the fastest way to regulate your nervous system that's also free is your breath. And I find that lots of people like to use their breath and I like to encourage my patients and my clients in this in order to use their breath to regulate their nervous system.

Because if you take a scale from one to ten of how we're feeling on most days at ten, being like, I'm so anxious and so panicky, I'm going to have a full panic attack. Zero. Being like, I'm frozen, I can't make any decisions for myself. I have to take a step back and close down. We probably live somewhere in the middle of that, right? It's good to have some stress in our life. Some use stress, not too much distress, but a little bit of stress is good. Right. If we start getting up on that anxious scale, like up to that seven, eight, nine range, it's like, this is not good because once I get to that ten, I'm going to go down to zero and totally shut down.

So using your breath work and whether it's just observing your breath or changing your breath, making your breaths longer and taking each minute to breathe right can be really helpful. I don't like to start most people off these days, I used to do this, but I recently found a different way to do it. So I like better, it's more effective, I found for people is observing your breath rather than changing your breath. And this is a somatic therapist that put together a module for us, vestibular Group Fit. Her name is Kate Schwab, and I want to give her credit for telling me this, but she told me that having people observe your breath, observe their own breath, rather than trying to change something can actually bring down that panic more because people who are trying to change something when they're already so hyped up and like, oh, my gosh, everything's so terrible. Adding something on top of that to try and do can be really help, really difficult. So instead saying like, oh, I'm breathing, I'm present, that's it, I'm present, I'm breathing, that's it. And kind of that neutrality of everything can actually bring things down. Other people prefer to take two, what is it, like four, seven, eight breaths or something like that? You breathe in for four, hold for seven, breathe out for eight. It just really is person dependent. So, yes, I love breath work. I think it's super helpful. It brings down that dizzy, anxious, dizzy cycle, which, again, is one of those things that I deal most with. So, yeah, I love it. Great. Wow.

So I just want to say thank you. Thank you so much for coming on today and sharing all this valuable information. I myself have been educated, and I'm sure everybody else has as well. This has been great. I've learned a lot, and I want to tell everybody to if you're on Instagram, you can follow Dr. Oaks at the Vertigo doctor. That's me. Yes. And I'm going to be including a link in the description to this episode today. She has a free Master class, and I'll let you kind of share a little bit about what that includes.

Yes. It's three steps to managing your dizziness. Basically, I think it's called Three Steps to Controlling Your Dizziness and Vertigo from Home. It's what I'm all about. I love creating dizziness. Obviously, I could talk about this for, like, six more hours, and then we'd have to be on a whole other podcast that lasts forever. But, yeah, I love talking about this. And so that's just my free kind of intro masterclass to how I treat my patients and clients with Dizziness and with vertigo and different vestibular symptoms to kind of help them get back to more function, reduce the dizzy, anxious, dizzy cycle and all that good stuff.

Thank thank you. All right, everybody, check out the link in the description. And remember, we do episodes every week on Wednesday. And thank you very much again, Madison. Of course, yes. Thanks so much, Cari.