ICU – “I SEE YOU” PODCAST
The Role of Medication in Treating Vestibular Disorders
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Vestibular disorders come with horrible symptoms, including vertigo, dizziness, nausea, and brain fog, to mention a few. It’s no wonder we all want a “miracle pill.” Unfortunately, no one treatment works for every person. In this episode of the ICU Podcast, the hosts talk to vestibular patient Lily Carillo who has been on that road, as well as Dr. Nicholas Hac, MD who explains how he determines what the appropriate medication is for his patients.
This podcast is a co-production of the Vestibular Disorders Association (VeDA) and Unfixed Media. https://unfixedmedia.com/
ABOUT THE GUESTS
Dr. Nicholas Hac: Dr. Hac is an assistant professor in the Comprehensive Neurology Division with an ambulatory focus in vestibular and oto-neurology and clinical practice as a neurohospitalist. Dr. Hac completed his residency at Northwestern in 2020 and a neurohospitalist instructorship in 2021 before pursuing a fellowship in vestibular and ocular motor otoneurology at Johns Hopkins University School of Medicine.
Lily Carillo: When Lily was in her early 20’s she had management positions that made her feel stressed and anxious. Then in her mid 20’s she had her first vertigo episode. It was scary and lasted about three days. She went to many specialists who prescribed medication for dizziness, but none of these drugs helped. In her late 30’s she had a vertigo episode that lasted more than a month. She couldn’t walk around her home and couldn’t work. Brain fog and fatigue were there everyday. Finally she found a vertigo specialist, and, as she describes, that’s when “the miracle happened.”
Hosts:
Cynthia Ryan, Executive Director of the Vestibular Disorders Association (VeDA) https://vestibular.org/
Kimberly Warner, Founder and Director of Unfixed Media https://unfixedmedia.com/
This podcast is a co-production of the Vestibular Disorders Association (VeDA) and Unfixed Media.
TRANSCRIPT
VeDA uses otter.ai to create machine-generated transcripts. This transcript may contain errors.
Cynthia Ryan
Welcome to the ICU Podcast where we explore the vestibular experience through conversations between patients and the health professionals who care for them.
Kimberly Warner – Unfixed Media
During this podcast, we invite patients to share their stories and healthcare professionals to ask questions, so they are equipped to better care for and truly see the invisible challenges faced by their patients. I’m Kimberly Warner.
Cynthia Ryan
And I’m Cynthia Ryan. And we are your hosts on this journey of discovery. Right Welcome, everyone. As our listeners know, vestibular disorders come with horrible symptoms, including vertigo, dizziness, nausea and brain fog to mention a few. It’s no wonder we all want a miracle pill to make it all just go away. Unfortunately, no one treatment works for every person, and it can be a long and windy road trialing therapies. Today we’re going to talk to a vestibular patient who has been on that road, as well as a health care provider who can explain to us how they determine what the appropriate medication is for their patients. So I would like to start by introducing our first guest, Dr. Nicholas hoche, who is an assistant professor at the comprehensive neurology division with an with an ambulatory focus in the stapler and odo neurology and clinical practice as a neuro hospitalist. And he’s gonna tell us what that is. Later. Dr. Hac completed his residency at Northwestern in 2020, and a neuro hospitalist instructorship in 2021, before pursuing a fellowship in vestibular and ocular moto neurology, odo neurology at Johns Hopkins University of Medicine, which I’m sure most of our listeners are familiar with one of the biggest and best balanced centers of excellence in the United States. So welcome Dr. Hac.
Dr. Nicholas Hac, MD
Thank you, it’s great.
Kimberly Warner – Unfixed Media
Dr. Haas, and welcome Lily carrio who is our patient today from Mexico City. We are really excited to hear Willie story when she was in her 20s She had management positions that made her feel stressed and anxious. We all know about that. Then in her mid 20s, she had her first vertigo episode. That was scary, and it lasted for about three days. She went to many specialists to prescribe medication for dizziness, but none of these drugs helped. In her late 30s. She had a vertigo episode that lasted more than a month. She couldn’t walk around her home and couldn’t work, brain fog fatigue. They were there every day. And finally she found a vertigo specialist. And as she describes, that’s when the miracle happened. Welcome, Lily. We are so excited to have you here today.
Dr. Nicholas Hac, MD
Thank you so much for inviting me today.
Kimberly Warner – Unfixed Media
So Lily, let’s actually just start with you. I want to hear a little bit more about your vestibular journey. We kind of summarized it, but I want to specifically hear about your relationships to the prescription medications prior to your vestibular symptoms.
Lily Carillo
Okay, well, in a nutshell, it was a nightmare, as we all patients that have this condition, no. When I started with this condition, I visited many, many doctors, they all prescribed medic, medicine for dizziness, like when you go in a boat, and you get a little bit dizzy. I don’t remember the name of all the drugs I took. But believe me, I think I took more than six or seven, maybe 10 drugs. And I visited many, many doctors. And no one knew exactly what I had. They looked at me with like the face like that. And that was the kind of medicine that they prescribed. It didn’t work at all. And then suddenly, I woke up and I don’t I didn’t have the symptoms anymore. But then I knew that it was coming again. It happened three times a year for many years. And it lasted from one day to two days or three days. until there came the time where it lasted more like when I was in my 30s 30s It lasted for a month. And then it was scary. And again I visited many doctors and The worst thing that I could hear from those doctors is when they said, I think it’s psychologic. Maybe you’re you’re having this because you’re thinking about it. And the more you think about it, then the more you feel dizzy. So that was for me very scary, because I thought it would never end. Yeah, it was a long journey very, very long.
Kimberly Warner – Unfixed Media
Yeah. What was what was your relationship to? Like? You said you probably took about 10 drugs. Were those? Were you hesitant to take any of them prior to any of these dizziness symptoms? Were you already a little bit hesitant to take medications? Or what was your prior experience with medication?
No, I did take the medications, because I really, really wanted this to go away. Yeah. So I took anything they told me to work didn’t work at all. And it was like a vicious circle. Because the more I got stressed, because of the conditions, and because of my work, the more dizzy I felt. So it was just a vicious circle. And I can some doctors that you got to calm down. I couldn’t, because it’s my nature. And I did have those management positions because of my nature. I wanted to be perfect. Everything had to be before the deadline. And everything had to be perfect. That that’s my that was the way I was when I was in that in those management positions. So it was a vicious cycle in every way. But I did take the medications that the doctors prescribed. I did want to be well. It was a nightmare. It was hard. Now that I think about it many, many years after I need to write a book, or I need to, I need to talk more about this because it’s like in this lifetime. Well, not in this lifetime. Well in this life. Right now. It’s like I was sent to to lift this, and it’s not funny at all. It’s not a nightmare. After all things happen now, and I’m fine, because I think we will get to that. What was the miracle cure? Yeah, I’m now helping people. So I think it’ll happen because now I may, I’m able to help patients with this condition from a psychological perspective, because I am a psychotherapist. I don’t work in corporations anymore, because that was very, very stressful. I love being a psychotherapist. So that doesn’t stress me out.
Cynthia Ryan
Yeah, I love that. I mean, it is we hear from so many people that their vestibular disorder has changed their life in many ways, including including their relationship to work or, or even the type of work that they’re doing. So and, and, and usually usually for the better. So I I’m excited to hear more about your journey. Dr. Hatch, I want to, I want to ask you, we know that you know, medication is one tool in treating this tubular disorders. And and it’s you know, there it depends on the type of vestibular condition that you have, and the stage you are at, in in your vestibular journey. Can you tell us what the role that medication does play in treating vestibular patients is?
Dr. Nicholas Hac, MD
Yeah, that’s a good question. It does depend a lot on what the cause of the dizziness is first and I think actually the most important part of my job is we need to get down to the root of why are you dizzy in the first place? Once you kind of figure that part out and categorize what the cause of the dizziness is, then you can go down okay, which medicines are more likely to work for these symptoms? So to give an example, I mean one of them one of the more common causes of dizziness is BPPV or Benign Paroxysmal Positional Vertigo. Most medicines don’t really truly help with that. And what I mean by that is if you’ve got some crystals or otoconia loose in your ear, at the end of the day, you just need to put those out Kodiak back. And back in the huge recall that the garbage disposal mechanism can eat a lot. For some people in order to do those maneuvers to treat it, you know, they need a little boost a little something so that they’re not so nauseated when they undergo the cannula, repositioning maneuvers. But that’s really just a bandaid. But then there’s a whole other category of patients. And these are patients who have perceptual causes of disease. These are things like vestibular migraine, triple PD, or persistent postural perceptual, dizziness, Malga, bark, mob syndrome, et cetera. And there are medicines that actually you can help to treat some of these conditions. So when it comes to vestibular migraine, for example, in theory, 20 of the migraine medicines could be helpful, but the way in which you take them is actually more in a preventive capacity. So that means that you take a medicine every day, and then you’re either less likely to get the disease symptoms, or when you do get the disease symptoms, they’re not as severe, or you get them for shorter periods of time. That’s just to give one example, at least for that particular disease, many, many people who go to doctors and whom they can’t figure out what the cause of the dizziness is, they may just give more of these medications that are just supposed to suppress the nervous system such as meclizine, or Benadryl, or, you know, benzodiazepines. And then the idea is that those medicines basically just suppress your brain kind of put you to sleep, and then you’re less likely to feel dizzy. But then once the medicine wears off, you still be. And so those medicines only work for a certain subset of patients, but they’re not really the end all be all cure by any means for most of these conditions.
Cynthia Ryan
I noticed. I think that you mentioned when you were you mentioned vestibular migraine, triple PD and Malda department in one category. And those are all central Vestibular Disorders, right? They affect the central nervous system is there, you know, a connection there between those conditions that affect the central nervous system being more prone to or benefiting more from use of medication?
Dr. Nicholas Hac, MD
Yeah, and I do you want to be clear that this is very patient dependent, right? Like, I don’t want to cast this broad net, where I just say, medicines are helpful for people with these conditions. But what I will say is that they can be helpful for people with these conditions. And the idea is that because these are all central Vestibular Disorders, but they’re controlled vestibular disorders that often happen, normal MRIs. You know, it’s very common for people to order MRIs and be like, Oh, well, I don’t see anything. So you know, who knows what the cause is. But that’s but in fact, it’s more the history that you get in the way that the dizziness behaves, that tells you what the problem is. So when you get that history that’s consistent with those conditions, there are certain medicines that have been studied for each of these that may be more likely to help. And the reason why I put them all together a little bit too is that some of those medicines overlap and are similar in each of these conditions.
Kimberly Warner – Unfixed Media
I know from for me, what I in hindsight now, eight years later, I my brain needed something that told it, it was safe, and not in a like short term period, but in a longer duration. Almost like when my cat is really scared. And then every little sound and every little light and every little change makes it even more on hyper alert. I get I so often think that’s what was going on with migraine at that time. And so, Lily, I know you tried a bunch of medications. Can you tell us some of those that you tried, what were their effects, side effects? I know they didn’t work. But do you have a memory of some of those specifically?
Yes, I remember the only one that worked. I think it’s circ that’s the name and Mexico, S E R C. I do not know the name for that medicine, but it was for dissonance when you’re in a boat or when you get off the boat. There was no excuse Meet,
Kimberly Warner – Unfixed Media
maybe magazine. Does that sound right? You know, watch
Cynthia Ryan
what that would be here.
Dr. Nicholas Hac, MD
S E RC
S E RC. I think that might be? Yes, something like that. Yes. Well, that kind of court. And it was for me a miracle. I remember that I took that when I was in my mid 30s. But when an episode came back, and I continued to take that medicine, it didn’t work any longer. So did work for for a time. All the other medicines did not work. I didn’t have any side effects. They just didn’t do nothing.
Kimberly Warner – Unfixed Media
Was that what was that like, emotionally for you? I’m curious, just, you know, being kind of a guinea pig. And you know, getting hopeful that something’s gonna work. waiting it out.
It was horrible. In all aspects. It affected me at my work, with my relationships, with friends with family, you know, people understand the beginning that you have something and there they are around you, and they are worried about you. But when they see that this doesn’t stop, or that you come back again, with no, I feel dizzy, I can’t go with you. I am not going to the party. They’re like, if you’re making this up, you know, I think I think you don’t have anything, you just want attention. And then you can just start to feel alone in this journey. Because nobody understands you. There are few a few people that do understand you like my mom, she was there with me all the time. She did understand me. And my best friend understood me. But my ex husband did not. And all the other relationships after that. They didn’t understand it either. So it’s very hard. And in a fix you and your job, because at the beginning that your boss maybe says okay, okay, why don’t you take some days off? But then it happens again, two or three months later, and people start like, let does she have the she’s sick again? Will she be dizzy again? Is she brain fog? How is she going to respond during the meeting? You know, so it’s very hard. It was very, very hard. It was a nightmare. So I know
Cynthia Ryan
that Lily, you said that. You tried so many medications and they didn’t work? Dr. Hac, I’m wondering, why is it that some medications work for some people and, and not for others?
Dr. Nicholas Hac, MD
You know, I think a lot of this is that people are just kind of toss a meal. If you don’t know what the diagnosis is, then you’re kind of just tossing darts at a bolt, you know, blindly and you don’t know what you’re even trying to hit. You know, at least based on the evidence that we have, for example, Willie, this medicine that you were taking circ or beta histidine. It’s traditionally used for many years disease. And so I would theorize that somebody may have thought that you may have many years many years disease, and that may have been why they thought it would work. And then maybe by responding to it, they continued to think that but that perhaps at the end of the day, this may have been a different diagnosis. I’m hesitant to theorize without, of course, seeing you in my clinic. But I do find that that’s a very common reason like when patients see me it’s often for third, fourth or fifth opinion. And they’ve told me all these therapies that they’ve tried. And I really just delve down at the history. And I think that there’s a couple of things that both Lily and Kimberly have brought up about this hypersensitive brain type of thing, where you feel like as though when you move you’re dizzy you feel as though when you’re exposed to bright lights or complex visual cues that you get dizzy. You know at work we have to get on Zoom calls or calls even like this. Somebody who’s acutely Dizzy may be very bothered by what we’re even doing right now, frankly. And so that does tend to categorize things more into those central or perceptual causes of dizziness such as What I mentioned before, like perhaps a vestibular migraine Melda, debark, mon triple PD. I really, the reason why I put all those together too is because I think I think of all of those as the hypersensitive brain disorders. I think that’s a really simple way that I talked about patience, or that I talked about these diseases with patients like you have a hypersensitive brain. And so what can we do to calm the brain down a bit? I actually even forgot if I even answered your question.
Kimberly Warner – Unfixed Media
That’s No, it’s great, because it actually leads into something I want to ask you, Dr. Hac around because of these hypersensitive brains. I bet you often see patients that have, you know, sensitivities to medications. And I’ve heard in this community that a lot of us do, or the doses are too high or so and I’m speaking for myself that I’ve had some freaky weird things happen, or they you take a sleeping pill, and it makes you feel really caffeinated. Like those kinds of reactions have been part of my history. So I was very reluctant to try medications, Lily, you sounded like you were just a go getter. You’re like, Okay, let’s do this. And I admire that. But how do you Dr. Hac talk to the patients like me that were like, God, I was so scared, and my brain was already scared. And then you add this medication on top of it, you know,
Dr. Nicholas Hac, MD
so yeah, I like to go at patient’s pace, because I talk about a lot of non pharmacologic things. First, to be honest, like I realized the focus of our conversation was about the medicines but I focus on the non medicine first and then when it comes to the medicine I just say you know, when you’re when you’re ready, let’s let’s pull the trigger. Let’s try something. It is very common to see patients such as Kimberly, who these hypersensitivity disorders, like you know, you’re you’re sensitive to light you’re sensitive the sound was was it the movement, you’re sensitive to seeing movement. And that also translates to your hypersensitive brain is also sensitive to these medications, I start at lower doses than most other people would. So, I mean, I’m talking about doses that are often below the recommended starting doses. So if I started a beta blocker like for panel, instead of starting at 40, twice a day, or at twice a day, I may even just start at enter 20 twice a day, you know, when it comes to pills like venlafaxine or affects or in which the smallest capsule is just seems 37 and a half milligram tablets. Sometimes people actually respond to just taking a few of them like breaking up the tablet, taking a few of the beats at first and then building up to that full dose of the medicine. Now if there’s any pharmacists who are listening, they may say, Well wait, that’s not how that medicine works and they are 100% Correct. But there is something about the hypersensitive brain that when you slowly build up these very low doses that in within those very small doses, in theory shouldn’t do anything. That slow buildup does seem to help patients with the hypersensitive brain.
Cynthia Ryan
I appreciate that you said that you don’t jump to medications first because that was going to be one of my questions is when do you talk to a patient about about whether medication is appropriate for them?
Dr. Nicholas Hac, MD
I talked about at the first visit, but most patients themselves will decide for themselves that they are not ready to make the jump. That’s that’s more common. But there are people who are very debilitated by their symptoms and they’re just like, look, I understand that there’s all these changes that I need to make in my life and I will make those changes whether it’s dietary changes or working with with certain therapists you know, I understand I need to do that stuff, but I would you know, I I am ready to make the jump now and try a medicine and so, for those patients, I will prescribe a medicine that first visit again I let my patients run the show on this I am very clear with patients too though, that in the world of dizziness patients is the name of the game. It’s not there’s virtually no medicines where I can just give you a medicine and suddenly the next day you’re fixed it just does not work like that. Believe me, I wish it did. I wish I I wish I could be out of a job and you know just there’s something some magic medicine a and I give it to everybody and then they’re fixed that’d be great. But realistically you need to take these meds sense for for six weeks and then you owe on average every day, the hope is that that dizziness starts to go away.
Kimberly Warner – Unfixed Media
So Lily, you did have a miracle. And I know we kind of jumped over that in your original summary. So let’s hear gets jumped back into your story and tell us when you met that vertigo specialist and what happened from that appointment?
Yes, that was the best day of my life. And by the way, Dr. Hot, you’re right. The medicine that they prescribed to me was a beta beta. Beta heisting, how do you say that? Yeah. Yes, they did prescribe that it was for the Munir syndrome. Okay. And that worked. But not for so long. Okay. Well, I finally I was very desperate. The last big episode I had that lasted for more than two months. That was in my mid 40s. So I went to the internet, and I started searching for vertigo. I think I typed in vertigo, and dizziness. And this clinic was at the top of the list in Google. And I looked at the page, I started answering the questions. There were about 200 questions that I had to answer before. I had my first meeting with the doctor. And it lists all sorts of questions, lifestyle, emotion, psychology, what did I do for a living if I have kids, if I’m married, if I’m single, if I’m divorce, all kinds of questions about my lifestyle. So when I finally went to the doctor, this word is very difficult for me in English, so I wrote it down. But Torino learned goal of just okay, I’ll say the otter Rhino or Toria. Know, that otter Rhino. Okay. I went to his how to say this, his clinic, okay. When I saw him, I said, Oh, my God, he’s a kid. How is he going to do something for me? This guy is about 20 years old or something like that. He looked very young. And he was young. And well, he had my history, my clinic history, he already knew about me a lot, because of all the questions that I find cert. And he ran a lot of tests, you know, audio balance, she put some goggles in my face, to see the stock know, the movement of my eyes. He ran all those tests in one day. And at the end of the tests, she said, you don’t have anything, you’re you’re fine. You, you’re perfect. And I was crying, crying. And I said, well, but then what do I have? And he said, it’s an emotional thing. It’s your you’re very stressed out. You, you need to calm down. I’m going to give you a cocktail. I’m going to prescribe a cocktail of ice ice soil anxiolytics and anti anti depressants. And he gave me a big dose. But I didn’t feel well with that visit. I said it’s the same thing. It’s it’s like all the other doctors now he’s only prescribing something different. So I went down and I said, Well, okay, I’ll do it. Because I’m not afraid of medicines. I didn’t know what I was taking. Because I didn’t know at that time what benzodiazepines were so I just did it. Okay, three nights after I took the medicine. By the way, I slept like an angel. I felt so well. I felt okay, I slept. Then I was very, very calm after that. Then after three nights, one day, I woke up and I was stable. I was fine. I was Oh my god. And you know, I didn’t want to move because I was so stable that I said no, no, don’t move. Don’t move. Don’t look. I finally was stable. And it felt wonderful. So I called the doctor right away. Hope it worked. Fine, and finally stable. Okay, Well, Lily, now you’re gonna do this. We cut down the dose dose of that medicine. And he said, we’re going to continue and call me within a week. And I did. So I felt well, the dissonance went away. I felt wonderful. I went to the office and I was liking heaven. Nothing worse. Nothing, everything was fine. I went into the meeting said, Whatever happened, everything was fine. The role is beautiful again. So that’s the way I continued with that with those method medicines. And I went to the doctor a month later. And then he said, Okay, now we’re going to stabilize the dose that you’re taking. And he said, I need you to go to therapy, psychotherapy. So I went to psychotherapy with a psychoanalysis psychoanalysis. And it was very interesting, because I started to learn a lot of things about myself that I had hidden under the rug. And nobody sees saw those things. So everything for me was perfect. But it wasn’t perfect. You know, suddenly, the floor moved under my feet when I was in my mid 20s. And it was all because of emotional things that I had going on. From things in the past when I was 10. So Well, I think with my psychoanalysts, and the auto renew the medicines, a change in lifestyle, diet, started to drink more water, I did many changes in my life. Many. I ended up a relationship that wasn’t working well, for him. Nor for me. I never had kids. So I did a lot of changes. In three or four years, my life changed completely. I still worked for that company. But now I took things more calm. Nothing’s gonna happen. No one’s gonna die. It’s not nuclear science. We were making greeting cards. It was just greeting cards. Why do I have to worry who’s gonna die if a greeting card doesn’t sell? Everything is gonna continue with or without greeting cards. So well. That’s kind of my story. And I have been taking those medicines for more than 10 years now. I don’t want to continue taking the bends. So dyestuffs. I’m Bensel. diazepam. Dr. Hac, is that right? How do you say that? Then? So? Okay. I don’t want to continue on that. Because, you know, I’m a doctor. And I go into Google. And I ask Google, what are the side effects of you if you take this medicine for more than 10 years, and when I read what happens, I’m like, Oh, my God, oh, I’m gonna have Alzheimer’s disease one day, I’m not going to be dizzy, but I’m gonna have this and I’m gonna have that and you know, you know, the way I am? Well, I started cutting off that medicine about three months ago with a psychiatrist, psychiatrist. And we’ve been working on that. And now I’m only taking a quarter, less than a quarter of a tablet every night. I will continue with the anti anti depressants. But I’m now taking only that kind of that dose of the anti the Einstein analytic. So I think that by the end of this year, I will be clear on that medicine, no medicine, not that medicine any longer. I will continue with the other one. And I’m feeling good. At the beginning beginning I was very scared because I thought if I if I discontinue the middle of the medicine, I will feel dizzy again. But no, I I’ve been fine. Because I no longer work for that company. I do things that I like and kind of retired. I’m about to be 60 years old. I have a different life now. I take care of what I eat. I don’t sleep very well. That is because the hormonal things. That’s something else the hormonal have had a lot to do with my dizziness But that’s a subject that I’m not willing to talk much about. Because the specialists don’t believe that the hormone change, hormonal changes have to do with dizziness. But I say they do. Because I felt it. And many of my women’s patients, yeah,
Cynthia Ryan
I think there is more research going on about that, that that we could probably talk about. But I have, I have a question because Lily you were talking about, and we hear this all the time from, from so many patients that, that contact VITA is there, there’s a really huge anxiety component that goes along with vestibular disorders. And, and it’s kind of this, this it’s a cycle, it’s also a murky area, it’s like, you know, for some people, anxiety can cause dizziness. And for some people, dizziness causes anxiety, and it is really hard to, to differentiate and to get to the cause of it. And also, I will just observe it, I’m not a health care specialist. So I’m speaking from a lay person’s perspective, and from someone who’s talked to a lot of vestibular patients, but it seems to me like the treatment for anxiety and the treatment for the anxiety that goes with, you know, a physiological vestibular problem are the same or similar. And so a lot of people are a little uncomfortable being treated with antidepressants, for example, for a physiological vestibular disorder, because they feel like their doctor is saying that it is all in their head or that it’s psychological. Or heck, how do you are Hac? How do you? How do you explain that to your patients? And how do you? It seems kind of like a sensitive subject.
Dr. Nicholas Hac, MD
Yeah, of course, such a great question, Cynthia. Yeah. So I’m glad that you asked that question, because it’s a sensitive subject, but I, in my opinion, that it shouldn’t be, I think some of this is just that we as a society, seem to downplay, you know, mental health disorders. And I see mental health disorders is the same thing as like, high blood pressure, you know, it you some you, sometimes you have it, and that’s fine. And and, you know, there’s a lot of different treatments for high blood pressure, you know, you can you can change your diet, you can take an antihypertensive medicine, but there’s a lot of different treatments for anxiety and anxiety is just one of the most common mental health disorders that people have. You know, in theory, it may be from some sort of chemical imbalance in our brain. And that’s often how I like to word it to patients. We know from fMRI studies that people with mental health disorders have changes in the way that their brains work, there are certain places that light up that don’t light up, and people who do not have these mental health disorders, there are certain places that don’t light up, that do light up and people who do not have these mental health disorders. And so this whole concept of it’s all in your head is a while technically, literally true. It’s it’s also, you know, there’s a very real physiologic changes that are happening in your brain that do lead people to have difficulty functioning and normal life. So I have always kind of theorized that some of these perceptual or central causes of dizziness may also be chemical imbalances in the brain. Do I know that? No, I don’t. And so is it any wonder that there may be overlap between anxiety or depressive disorders as well as some of the perceptual causes of dizziness such as triple VD or vestibular migraine? In theory, if you have chemical imbalance in one maybe you have a chemical imbalance in the other. Now that’s that’s just getting at the chemistry but also in just a more human terms. I think that anxiety already is very common and and dizziness can certainly be a trigger for underlying anxiety symptoms. But then likewise, it’s very understandable that if you are walking around and the whole world is swaying, tilting, or rocking or whatever it is doing, I mean, wouldn’t you be anxious about that? I think. And so there’s just a very normal and understandable reaction. And so I’m clear with patients that you know, it almost doesn’t matter which came first the chicken or the egg, it’s just very common to have both of them at the same time. And because we have both of them at the same time, it it’s probably the case that when you are anxious, you feel your dizziness more, just because also when you’re anxious and if you have a stomach ache, you’re probably going to feel the stomach ache, more anxiety just worsens all medical conditions, not just dizziness. So, you know, I, that doesn’t necessarily mean that the dizziness comes from the anxiety, but that anxiety will worsen it. And then likewise, the busier that you get, the more anxious you get over your disease symptoms, right? I mean, the world is weighing more, I’m, I’m going to be more anxious about that, you know, I mean, everybody would, so I’m very, I tend to be clear about that. But they’re they both tend to coincide and oftentimes the best treatment regimen is to address both of them. And so for example, if you have something like the circular migraine, that may mean you know increasing that water intake I’m trying to be a good example here by having my cup of water getting getting more sleep at night. You know, adjusting your diet to a more migraine and there we go, Willie. Alright, so this is an educated crowd here. But it also you know, all of that stuff, changing your diet, it may mean migraine medicines, but it also may mean addressing the underlying anxiety or depression too, that is likely feeding into the dizziness which is also feeding into the depression or anxiety. Really, it’s the best way to treat it is just a dress both problems head on. With the anxiety, depression, psychotherapy, super helpful. No Talk therapy, cognitive behavioral therapy, met anti anxiety, elliptic or anti depressant medications can be helpful to even just taking time to take care of yourself every day, whether it’s some form of mindfulness activity or being something fun for yourself. You know, a lot of my patients do have these. They’re high functioning, and they don’t have enough times time for themselves. They’re at a job where they just feel like they there Go, go, go, go, go, whether you gotta get to work, gotta get the job done. They’re not taking time to take care of themselves. And then likewise, you know, the, there’s medicines for vestibular migraine to that overlap with these anti NCL litical, anti depressant medications. And so isn’t it nice when you can take a medicine that actually killed two birds with one stone, so to speak? And that’s a common situation that I encounter. And I do talk to my patients about that too. Perfect. explanation. Thank you.
Cynthia Ryan
I have a question. Lily you were talking about? It was Dr. Jorge madrigal, who, who had you? You saw in the end? And he is a I think you said he’s an Orion ologists. Right, or an otolaryngologist? You also mentioned seeing a psychiatrist now. So this is a question for you, Dr. Hac? Who is it that prescribes medication, what kind of health care provider is it that prescribes medication?
Dr. Nicholas Hac, MD
Some of this is up to the comfort level of the various providers. So when it comes to some of these anti anxiety or anti depressant medications, you know, of course psychiatrists are comfortable with that. I think that me as a disease specialist, I am also comfortable with it because I have this extra year of training in this and and I feel a bit more comfortable with the side effects of these medicines and the potential benefits and when should I not be prescribing these medicines to? So there are some neurologists who will do that there are some EMT, that’s what I prefer to call the, the those those positions just because it’s much shorter thing to say, there are some EMTs who feel comfortable with it. So it’s a little bit dependent on the practice environment that you’re in as well. Even even primary care physicians, and I keep mentioning physicians, but of course, you know, APNS NPS also feel comfortable prescribing some of these medicines who And so sometimes primary care physicians or primary care providers will also feel comfortable prescribing some of these medicines. Some of it some of the time, it’s with the guidance of somebody. But it’s really difficult for me to precisely answer that question, because I think all of us come up with, we all have different backgrounds, and what is our comfort level with certain medications and certain patients? Primarily, it’s
Cynthia Ryan
met, I mean, medical doctors are the primary health care provider that can prescribe medications, right. Yeah. I mean, you don’t go to your physical therapist or your audiologist for that.
Dr. Nicholas Hac, MD
Right, right. So when I when it Yeah, so so that’s a good point, when it comes to dizziness, oftentimes, audiology, physical therapy, but it can also be psychotherapy, as well, for these patients that we’ve just been talking about, who also have coexisting depression or anxiety symptoms. All of these providers generally do not prescribe medications. And so you do need to go to a do MD, or APN, or NP, one of these roles in order to actually get those medicines.
Kimberly Warner – Unfixed Media
So really, I’m so I’m so happy to hear that you’ve had your magic pill experience, or Miracle moment that has continued on in your life. And I, too, have had that in the sense that and I want to clarify, because I still feel dizzy, I don’t know if your experience is the same. But what my my brain doesn’t care anymore. So what the medication did for me is here, it’s definitely not as heightened, but it’s always there. But I just it just is falls into the background, I can ignore it for most days, and I just doesn’t like it doesn’t bother me anymore. Whereas before I was, you know, very hyper vigilant about it. So I want to hear from you, Lily, what would you say to a person who was looking for that magic pill cure with vestibular vestibular condition?
I think the most important thing is, as Dr. Hac said, patient, you have to be very, very patient. And you have to find the right specialist to have the diagnosis. If you don’t have a diagnosis, it’s harder. But once you’ve heard from the specialist, what the diagnosis is, and he tells you or she tells you what way is the best way for you to go. Because it’s something that you work with your doctor. And you have to be talking with the doctor to see how you’re doing and have feedback from him. So okay, to answer the question fast, you have to get a diagnosis. But you have to get the right specialist. Because if you don’t go to the right specialist up, go continue going to visit many, many, many doctors that just don’t have a clue. They don’t understand you. So that’s the first thing. In Mexico. Fortunately, we have Dr. Jorge madrigal, who is the specialist that I recommend everybody to go to see. He’s based in Mexico City, and he also has a clinic in another town in another city in Mexico. That’s why Allah Hara, and there’s another clinic in Colombia. And he has many, many contacts in all South America and in Spain. And I think they’re now working with some brands, or many other doctors in this in the United States that you also have specialists for producing this. So it’s getting better now for us patients, because nowadays, you can find specialists 30 years ago, there weren’t specialists. So that’s the first thing I recommend the patients take the medicine or do whatever the doctor commands, be patient, go to psychotherapy, and things will work out. I know many people continue to be
Dr. Nicholas Hac, MD
oops, oops,
Cynthia Ryan
looks like we lost Lily. We haven’t we do sometimes have connection problems. But I want to just continue on with what Lily was saying about finding the right specialist. That is, you know, when when people come to Vida looking for help, that’s the first thing that we do is we get them connected to a specialist and we have a directory of vestibular health care providers on our website. So anybody can come in and find someone and sometimes you know, it’s hard for people who are in rural areas. Because there isn’t a vestibular specialist, but with telehealth these days you have better access to care, you know, your provider can can work with a vestibular specialist who is in a different city and a Balance Center. So, there’s and there’s Lily again. I really, really we were, we were continuing with what you were saying about finding a specialist and how to do that through VITAS provider directory, and definitely how important that is. So thank you for for sharing that. Dr. Hatch. I’m wondering, and I don’t know, if you if you have, you know, insights into this store or knowledge about it. Are there any? Are there any new medications in the pipeline in the research pipeline? And I know that research is one of those things, it takes a long time. You know, even even if there is, you know, a medication that’s in the pipeline, patients might not get access to it for years. But anything that you think that is out there that looks like it could be, you know, and I’m not going to call it a miracle pill, but something that could help patients in the future.
Dr. Nicholas Hac, MD
I mean, the answer is, yes. Fortunately, one one caveat to all of this is, you know, when it comes to migraines, for example, I think that there’s a lot of great research as far as like what medicines can be effective for migraine headaches, but we have very limited data in which we’ve specifically studied regular migraine compared to like the migraine headache disorders. And so are these entities really different? Do they have a similar underlying pathophysiology, we don’t necessarily know per se. But with that said, you know, at the end of the day, I’m still a neurologist, and I take care of migraine headaches, and not just vestibular migraine, and there’s many new medicines that have come out for migraine patients. And so in particular, the CGRP inhibitors. So these are, some of them are like once every 28 day injections versus oral pills may be effective for many of these patients who have the similar migraine. I believe that there is a study going on at UCSF to explicitly see if these medicines can be helpful for just regular migraine in the form of randomized controlled trial. So we’ll see what the results of that are, but also just my personal experience, I have just learned people are migraine patients on this, and they have gotten some benefit from it. So that’s one of the big ones. And I think I think what I also would say is that we’re also making some strides even in like the full PD, persistent postural perceptual dizziness, you know, this was described less than 10 years ago, by Jeff, stop at Mayo, who wrote this great paper on how SSRIs and SNRIs, which are traditionally antidepressants can be helpful for this particular cause of dizziness. And so, you know, when we are better describing these conditions, it does kind of kind of push us forward in terms of what medicines may be helpful. So those are those are the things that I have noticed, and I mean, the CGRP inhibitors in particular for migraine came out, like within like last five years. So it’s pretty exciting.
Cynthia Ryan
Thank you for sharing. And, you know, I just want to say for our listeners, I know, when we’ve had other discussions about stimulant disorders and medications people get very specific about well, what about this? What about this, I know we have not covered all of the medications, it’s really, you know, it is very specific to the patient. And there are many, many options out there. So I encourage everyone to find the right provider like Lily was saying, and talk to your healthcare professional about what’s going to work for you.
Kimberly Warner – Unfixed Media
I feel really hopeful after listening to this conversation, I feel like Dr. Hatch, knowing that people like you and physicians like you are are practicing and helping create change for vestibular patients is is very different than what I felt eight years ago. So I’m I’m optimistic that we’re just going to keep going in the right direction. And Lily I’m so happy to hear where you are now. Well, so thank you both for this wonderful conversation. Thank you.
Dr. Nicholas Hac, MD
Yeah, Have you
Cynthia Ryan
thanks for tuning in to ICU this month.
Kimberly Warner – Unfixed Media
We hope this conversation sparked new understanding of the vestibular journey. And for all of our patients out there, leaves you feeling just a little more heard and a little more seen. I see