Broadcast Journalist Deborah Roberts on Living with Migraine

Episode Transcript

Dr. Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa.

Dr. Peters:
And I am Dr. Katy Peters. And this is the Brain & Life Podcast.

Dr. Correa:
Welcome back from a few weeks of cheering on the athletes from around the world and their amazing accomplishments. Now, on the other hand, if you're more like my wife and not a huge fan of competitive sports, welcome back also to your regularly scheduled programming. So Katie, what stuck with you from the Olympics from the last few weeks?

Dr. Peters:
Oh my gosh, so many, many things. Where to start? So I'd say first the gymnastics is just so amazing. I believe that Simone Biles can get up to 12 feet in the air. Again, amazing. I love it when the home country sort of has a hometown bureau. So that French swimmer that just was like a rocket in the water. He excited the host country so much.

Dr. Correa:
[inaudible 00:01:04] Léon Marchand.

Dr. Peters:
Yes, Léon Marchand. I hope he didn't swim in the Seine, but hey, I think that the triathletes did swim in the Seine, didn't they?

Dr. Correa:
They did, yeah. And thankfully many of them didn't get sick and we saw amazing competitions.

Dr. Peters:
Yeah. So I enjoyed cheering on the US but also all the other countries too. It's so much fun to hear people's stories and how important it's for them to be there.

Dr. Correa:
Yeah. I mean, you see the importance of what it means to them and to their families throughout the shows and every aspect of the competition. I also was inspired by Simone Biles. It was great to see her overcome the twisties and her challenges, but only to become stronger in her sense of self and her love of competition. It's great that she got gold medals, but it was more than anything else.
It was great to see her really fulfilling herself. This week we bring a discussion with an award-winning news correspondent Deborah Roberts. And aside from seeing her on TV, many people may not realize she has lived with vertigo and migraine. So not the twisties necessarily, but for many years this has been a challenge for her in her own day to day and work. Katy, have you ever had a migraine or vertigo?

Dr. Peters:
Oh gosh. I had acute vestibular neuritis, which can cause vertigo once and it was miserable. I was glad to recover and did some vestibular rehab, which is really important to sort of get over that. But it was actually during medical school and it was during my obstetrics gynecology rotation. It really cemented that I'm a neurologist and it was not a good time to try to deliver babies when you're very vertiginous.

Dr. Correa:
Yeah. I had a concussion once while wrestling in high school and the vertigo that I got even just for a few minutes afterwards has me really truly understand how much it can impact people when they have it as a more chronic condition. But particularly if you want to learn more of the overlap between the association of the symptom of vertigo and headache disorders, make sure you stay tuned after my interview with Deborah Roberts to hear from our medical expert, Dr. Matthew Robbins, a headache specialist from Cornell Medical Center.
I hope you enjoy this episode and we look forward to hearing more of your questions. Welcome back to the Brain & Life Podcast. Now I'm here today with someone who you have all seen on TV in many different ways. Deborah Roberts is an award-winning 20/20 correspondent in co-anchor of the prestigious News magazine, 20/20. She's a media veteran who has traveled the world for her reporting.
You may have seen her also on Good Morning America, The View, she's won multiple ME awards for international and national coverage of various world events. In addition, she's a New York Times bestselling author. Truly inspiring. I'm not really sure how she finds the time. And throughout all this, she has traveled and reported from around the world at times coping with vertigo and migraine headaches. She's also been actively raising awareness about balanced vestibular disorders and migraines. Deborah, thank you so much for connecting with us in the community.

Deborah Roberts:
Happy to be here, happy to be able to talk about this and shed some light on a topic I hope will help other people.

Dr. Correa:
So in an issue of the Brain & Life magazine, you share some about the start of your vertigo symptoms in the 1980s. Let's go back before that. What do you remember that was different about moving through life in the world before these symptoms started?

Deborah Roberts:
It's interesting because I hadn't thought that much about the history of all of this until I started speaking with you all about it. I remember, now, I'm going to start self diagnosing and I'll have to go back probably and either speak to a therapist or maybe find my old childhood doctor. But I do remember just first of all, life being just fine growing up without many problems.
But I do remember at one point when I was a child, I think I had a collision accident. A bunch of kids were playing and I banged into somebody's head or something like that. And I did have a little bit of an eye issue and wound up wearing glasses, but my family wears glasses, so it wasn't a big deal. But I did have a little bit of a muscle issue with one of my eyes. So I went through life with that knowledge. And like all kids, you have bangs around the house and so forth.
I was a cheerleader and I was active in school, so I don't remember anything really traumatic. But later in life, and I don't ever think I remember having any blurred vision, any dizziness, anything related to vertigo until this one in the 80s when I had started my career and I was working down in Orlando, Florida and I was on my way to an assignment and all of a sudden I just saw this aura, almost like the blurring of the periphery of your vision.
And I could just sort of feel a headache, like this weird wave coming over me. And I had never experienced that before. And I was in the car and I just thought I was getting a little bit carsick. I was with the photographer I was working with and I thought I was just somehow experiencing some kind of dizziness or motion sickness or just something out of the blue and I had to put the seat back and lie back.
And I just remember just feeling really nauseous and just really, really horrible. I don't remember how long it took. Maybe it took the length of the time that we were going to our assignment that maybe I started to feel better. But I remember just that significant day and I just felt sick to my stomach and so forth. And it passed.
I probably took some Tylenol or something like that at the time just thinking maybe I was having just some bad headache and it went away and I never thought much about it, except maybe I had another occurrence at some point in life. But I never really connected it to anything. I just thought maybe busy, running around, stress related kinds of things would happen to me. So I never really thought about it until another time, much later in my career when I was on vacation with my family.
Well, I actually had been on an assignment again. I think there may be something connected here to me and the work and the stress, but I was traveling and I think I had been somewhere in the mountains either Utah, Colorado or someplace like that. And I remember having what often people get there, which is you get a little bit of dehydration and you get a little elevation sickness. And I just remember feeling a little bit off and then I went to go join my family on vacation in the Caribbean and we had a perfectly lovely time.
And on the way back before I could even get dressed to leave that next morning, I couldn't get out of bed. The room was spinning. I was so nauseous. I had never experienced anything quite like that before. And it just came out of the blue, had no idea where it came from. And that was sort of the first really big attack of vertigo, maybe migraine, that I really remembered in my adult life that I started to then connect and think something is wrong.

Dr. Correa:
And do you feel like each of these events ended up also coming with what you perceived as a headache or sometimes they seemed disconnected?

Deborah Roberts:
The second time this happened in a big way. I woke up in the morning and it just happened. So I don't remember anything in particular except that I had been on this one trip. I had been at a very high elevation and now I'm down in the Caribbean and obviously a much lower elevation. I had been swimming. And so I think I probably just associated it with just being very busy and maybe going from one climate to another.
I don't know that I associated it with anything in particular other than it was just, it walloped me. It really walloped me. And it took all morning before I could sort of get myself together. And I remember my husband had to grab my arm, I had to lean on him to be able to make my way to the plane and get on the flight and so forth. So that was one that just was really bad. And I don't know that I really could say for sure, but interestingly, each time I was sort of busy and maybe a little bit stressed and traveling.

Dr. Correa:
And so now you, at this point, you've had two different episodes that kind of, as you said, walloped you out of surprise with no way of predicting that they were coming on. Many people deal with different episodic or periodic conditions where symptoms or an event can happen unexpectedly and that can bring on a lot of stress about not knowing when it's going to occur. Did you experience anything like that and how did you handle in figuring out, getting some management of this?

Deborah Roberts:
Well, when I got back to New York, I do remember making an appointment with the ear and eye infirmary, or I forgot the name of the hospital, but it's a very famous institution down here in the city in Lower Manhattan where they treat these kinds of things. But keep in mind, this was probably 20 years ago or so and we still don't know a whole lot about vertigo and why it happens.
I guess the population effect, it just isn't large enough that there's been huge studies. So I did go and make an appointment and I did meet with this doctor who talked to me a little bit about the crystals in the ear. Many people have heard things like that or he basically said, "We just kind of don't know." But he did work with me with some therapy, some physical therapy, what he called, I think it was Hawthorn's neck exercises.
And so it was all about rolling my neck back and forth and almost trying to reset yourself. And he sort of indicated that the best thing was just to sort of work on exercises and certainly there was no real medicine that would take care of it. So that helped me going forward after this particular episode. And I kind of didn't think much about it. But yes, to your point, I was a little on guard.
I think if I was really busy and very stressed because I remembered talking to friends who said to me, "Oh, my husband or my wife, or I know a friend who suffers from vertigo." And each person described events like travel and dehydration and getting very stressed. And so I thought maybe that had something to do with it. So anytime I had any of those events coming up, I think I would be on guard a little bit for the possibility of it happening. But then I would go for long chunks of time with nothing and I just sort of put it out of my mind and forget about it.

Dr. Correa:
And between friends, everyone seems to have a suggestion, especially when you bring up that you're having any kind of medical symptom. Then you're plugging it into Google or any kind of internet resource. Yeah, as you said, you find so many different things. How did you put in context and figure out for yourself, what were your own triggers? What did you identify that worked for you in terms of managing symptoms or helping prevent or reduce them?

Deborah Roberts:
That's a very good point because I think you do have to sort of just take matters into your own hands, especially if it is sort of sporadic in the way I suffer. I think I just became acutely aware of very busy times. If I'm traveling a lot, if I'm drinking alcohol, say there's been, it's the holidays and I've been to Christmas parties and it's been a week of a lot of drinking, I'm sort of conscious of the fact that I've been drinking and I could be dehydrated.
And especially if I'm about to embark on a lot of travel and I travel a lot for ABC News for my work. And if I'm very stressed, just trying to take care of a lot of different things and multitasking. I'm a very busy mother and wife and sister and friend.

Dr. Correa:
Very busy.

Deborah Roberts:
Very busy. So I'm always on alert when I have all of those things going because I know that that's a possibility of getting maybe overstimulated. I'm not quite sure. And really only after talking with you all and sort of embarking on this journey to talk about it, have I been motivated to really sort of branch out again and see what I can find out. So I actually mentioned it to my internist the other day when I went in for my annual checkup and he began to wonder could I have something going on with my neck?
I'm a big workout enthusiast, and so I try to be strong. I work on weight training and all of that, but he began to wonder if there's something going on also in my cranial region of my body. So this whole is a mystery still. We're all trying to figure it out, but now I'm going to go and try and look into that and I'm going to have an X-ray and just see, could that be the root of some of this? But at the end of the day, we haven't pinpointed what's officially happening to me and why and when.

Dr. Correa:
Well, our bodies are a wonderland.

Deborah Roberts:
True.

Dr. Correa:
I mean, there's so much to learn and figure out, not only from our own brains and the brain in general, but just everything about how we live.

Deborah Roberts:
Agreed. And I think we have to stay in touch with our bodies too. And this has really led me to think a lot about what I'm doing, what triggers are happening. Whether it is this or anything else in life, you really have to stay in touch with your body and what you're doing because only we know what our bodies are doing and telling us for the most part if we pay attention.

Dr. Correa:
And how do you keep track of this and discussing with your internal medicine doctor and the specialists that you see to manage these symptoms?

Deborah Roberts:
Well, I have to be honest with you, I'm not the most organized person. I'm not a journal keeper. I'm not somebody who's really jotting down like, "Oh, this last happened to me back in December of whatever and this was going on." I'm not very good at that. I am very good though at being attentive and paying attention. So I have to truthfully tell you, I just sort of go with the flow. I mean, I try to be a very healthy person to begin with.
I try to eat healthfully. I try to, I work out like five days a week or I run or work out. And I try to stay very active, but I'm also just a very busy person. I mean, I'm a mom of now grown children, but I have a career that really keeps me going. So it's really hard to just pinpoint and keep track of everything.
But I do try to be aware of my schedule and what I'm putting into my body and how much I'm taxing myself knowing that I can be vulnerable to vertigo and migraines. And I don't know that the migraines are anything that I can really quite pinpoint. The vertigo, yes. I can kind of say I can sense that coming if I've done certain things. But the migraines are something that are almost separate. Sometimes they come together and sometimes they are separate.

Dr. Correa:
Wow. And you've mentioned already multiple things that you're doing, not just 20/20, but so much other work, your family. And you said you try to keep attention to all the different things that you have going on, but do you have any quiet points?

Deborah Roberts:
That's a very good point, and I try to do that. Yeah, I need to work on that more. And I have to say it's a practice like everything else. I have friends, George Stephanopoulos at ABC is a big meditation person, and Dan Harris who used to be with us and left and created Headspace is very big on meditation.
So I know people who do and I admire the people who do, and I think I've got to make more time. So when I get into a routine of the practice, I do find that it is helpful and I will say that is something I think I do need to work on more in my life, finding those quiet moments, finding that time, whether it's 15 minutes or maybe hopefully a little more where I can just sit and be and meditate.

Dr. Correa:
Yeah. I think that first part of finding the spaces for quiet and time for ourselves and our body to listen to our body, and there may be other complimentary practices out there along with everything that we're doing for our overall health. Deborah, let's go circle back at the center of it all. What has driven you to find and tell the stories from your reporting over the many years? I mean throughout all of these, the challenges in growing your family and living this very multifaceted life, what has been the drive to keep coming back to the stories?

Deborah Roberts:
I am just a passionate and curious person, and I always have been. My brother, my oldest brother told me recently, "I just remember when you were little, you always asking people questions. You were always wanting to know the when and the why." And so I guess from childhood, I've always been a very curious person. And so I of course fell into this career that just satisfies that drive. I love, love, love what I do. I love getting a chance to meet people, to travel to places that I never ever would've probably ever gone to.
I mean, to go to Lesotho, Africa to do a story about the HIV/AIDS virus, to go to Bangladesh and report on maternal health with women or some part of the United States in Kalispell, Montana and to talk about a story that happened out there of a mom who had lost a child. So I just am so motivated to get out and meet people and discover things and share them with people. So I think it's just in my DNA. I've always liked talking, sharing, meeting people. And so at the core that's kind of what I do. And also just sharing these stories.

Dr. Correa:
And through these experiences, I mean, you've encountered people and reported on situations that both health crises going through major social strife and other health conditions. Whether it's specifically from people dealing with medical conditions like neurologic disorders, other people living with vertigo or many of the other situations you've reported on in general, what have you learned from others about resiliency in moving past challenges like this?

Deborah Roberts:
Oh, that's such a great question because that's one of the things that I have to say I feel blessed in a way to have this profession. Because I have an opportunity to be kind of a student of the world, and I have learned a lot. I mean, I do a lot of reporting on people who have endured traumas and difficulty. I mean, in addition to some things that are a little bit lighter and happier. But I've met children in far reaches of Africa who lost their parents and are running their household as children to make sure that their brothers and sisters are taken care of.
And I think about when I'm reporting on these kinds of things, I think back to my own kids or my own community and people I know who are complaining about things that are maybe in abundance of things and maybe just affected by having too many choices or just not being able to function well because of really in a way the circuit of things that we have. And then you think about kids who have found either some happiness, some joy, some contentment, even in just the most basic things.
I remember when I was in Namibia once working on a story and just as we were just taking pictures and video of this little community or this little village, these kids had these rubber bands that they had just somehow compiled and piled on and tied together and made a ball, a ball that was made from scraps and rubber band, and they were playing soccer and just having a great time and laughing.
I just remember thinking, "Wow, wow, wow, wow. My kids would be..." And my producer said the same thing. "My kids would be screaming and crying and complaining about this or that, or maybe I just lost that game." And these kids were finding a little bit of joy in something very simple. And that just was something that I took to heart and I took back with me.
And I've learned over the years too, just in other reporting that I've done that people who have to struggle in life, particularly people in developing countries, have a brighter sense of hope and resilience, which is so mind-blowing to me, than people who are in countries that are developed and have so much more because they know the fragility of life, they know how difficult life can be, so they grab on to the little moments of joy and hope and inspiration.
And so that's really kind of, I think informed my life a lot when I am working on, when I'm doing anything. I think a lot about the people that I have met, people who have been able to pull themselves together and find a way to not only put one foot in front of the other every day, but to find some hope in spite of dire circumstances.
And I've learned that people just, we are capable of that, but we just have to believe that we're capable of that and to believe in some ways that that's kind of the only choice we have. You can be defeated or you can sort of decide to move forward with some hope. And I've learned that and that has really, I think helped me a lot in my life when I'm dealing with something difficult.

Dr. Correa:
And do you think we have to suffer to have joy?

Deborah Roberts:
I think we kind of do. And it may not be great suffering. Let's pray it's not great suffering, but I think you cannot compare being happy. I mean, I'm very active on social media, and so I like to try to spread joy. And my brand on my page is really for the most part about finding a little silver lining. And occasionally I've written about that, that maybe I had COVID twice, like a lot of us have in this country, or if I've had some other bad something or another flu or something and just felt so awful.
And then once you start to feel better and that first time you sort of step outside and you're walking to the grocery store or maybe I'm walking to the park, I suddenly think to myself, "Wow, you almost have to feel lousy to know what it is to feel great and to appreciate what it is to feel great." So I really do believe there has to be some suffering in your life to be able to appreciate the beauty and the joy and the optimism in life. I don't think you can know what that is all about unless you can compare it to something that is not very joyful and hopeful.

Dr. Correa:
I think at every level, the human experience we all will have and experience some suffering, but taking the opportunity to reflect and find the things that we're grateful for, I think helps find the joy and harness the joy in our lives. Now coming back to someone else struggling and in the situation of living through vertigo, vestibular migraine or migraine and a similar situation of what you've experienced, what advice would you give them and finding a diagnosis or their own management?

Deborah Roberts:
I would say to people, you can't ignore it. You got to pay attention to what's happening. It's easy. And especially something like that that can feel debilitating at the moment, it's easy to sort of feel defeated. And I think you've got to reach down and believe that you can overcome it. You've got to pay attention to your body. You've got to think about triggers. You got to think about what you can do to help yourself. Because oftentimes the explanation is elusive.
I mean, yes, you can make doctor appointments and you can go and see what you can find out. And I think that's so important. I mean, you have to work hand in hand with your doctor, but I'm not a big believer in just being medicated. And oftentimes if you go to visit a doctor about something, the answer might be some kind of medication or maybe something to dull the pain. And that's helpful at the moment, but I want to know holistically what I can do to try to make my life better.
So I think you have to be invested in making changes if that's what it takes, checking in and paying attention to your health, seeing what you can do to sort of make yourself healthier and certainly happier. But I think paying attention, you have to really pay attention. And then also believe. I mean, for me, on a regular basis, I have to remind my husband every now and again when we're talking about something and I kind of mentioned that I've got a headache and he's like, "Wow, what's going on?"
And I say, "Honey, you know I suffer from these from time to time." That it's just something I've learned to live with. And so I'm not advocating suffering in silence, but I do learn to just kind of go forward and I'm not going to let it rule my life or control my life. I mean, right now I feel headache free and I feel perfectly great and happy as I'm talking with you.
I'm looking forward to having a slice of cake later this evening, but tomorrow I could just as easily just feel like this sort of grainy little weird headache when I wake up in the morning and I might just not feel great, and it might take me a little while to get going. But I'm going to keep going and I'm going to go out and I'm going to try to conquer and seize the day.
And oftentimes the whole situation will ebb and it's better, and but mostly I'm living life and I'm getting there and I'm still doing what I need to do and want to do. And so I think I would say don't let it crush you. Try to figure out what's going on, try to fight back, try to help yourself and just stay in tune with your body.

Dr. Correa:
And for our listeners, we're going to be sharing resources both in the article in the Brain & Life Magazine and in the show notes about vertigo, vestibular migraine and migraine, and also support groups and organizations that offer more information about these conditions. But Deborah, from your perspective, for those who don't understand and haven't had the experience of vertigo and migraine, what do you want them to understand about this condition and these symptoms?

Deborah Roberts:
My philosophy is never woe is me. And I'm never one to think about myself as somebody who is ailing or dealing with something that's worthy of some kind of sympathy or pity because it's not that kind of a thing thankfully. But I would say that it's a real thing. It's something that's difficult. And I forgot, I read a number the other day about the number of Americans who are living with pain and there was a large swath of Americans who live with some kind of discomfort or pain every day.
And I think that this is sort of in that category too. It's not pleasant, it's not easy. I think you never know when you meet people what they're dealing with. I mean, we've heard so many people say recently, particularly during this time in our nation where there's so much toxicity going on, "You never know what another person is going through."
I would say you don't know what another person is going through. And it's the difference between, to me being able to just live your life and feel great and happy and living your life with a little bit of struggle or a lot of struggle depending on the extent of it. And there are days where I'm just not feeling myself. I'm really having to dig deep to go out and do an interview or go out and meet somebody or go to an event and just try to be pleasant.
There are plenty of times where I just don't feel great, but I'm trying to get through it. So I would say just know that there are a lot of people out there struggling, and it may not be a big struggle, it might be a small struggle, but struggle is struggle and just to be patient and to have some empathy and some sympathy. And I think more than anything else when I'm going through these kinds of things, it makes me more aware that there are a lot of other people who are dealing with things, some things that are worse, but certainly dealing with stuff. So let's be patient and more giving and compassionate toward one another.

Dr. Correa:
I can tell why you are award-winning in many of your shows. I just want to keep talking. I have so many questions.

Deborah Roberts:
Oh my gosh.

Dr. Correa:
I want to hear more and more. I know our listeners do too.

Deborah Roberts:
I hope this is helpful and I hope it also shines a light and lets people know that they're not alone. We're all dealing with something. There is usually some kind of help and opportunity to get better. And a lot of it is just a state of mind too. You really want to feel like it's something worthy of getting better over.

Dr. Correa:
Now for our listeners, stay tuned. We'll be continuing our discussion with our medical expert to discuss vertigo, vestibular migraine, migraine, possible holistic approaches so that we can all understand the conditions better, be more empathetic of those living through them, and find our own ways to manage and live better with the symptoms. Thank you so much, Deborah.

Deborah Roberts:
It was a pleasure.

Dr. Correa:
Can't get enough of the Brain & Life podcast, keep the conversation going on social media when you follow @NeuroDrCorrea and @brainandlifemag, or visit brainandlife.org. It's wild to hear Deborah Roberts in this kind of more casual discussion. We're so used to seeing her on TV and hearing her interview other people.
I can't imagine my challenge of turning it around on her and as a neurologist and not experienced interviewer to get a chance to hear from her and her life experience. I really appreciated her sharing her experiences with Vertigo throughout her life from the 80s until now, and moving through with symptoms of vertigo and migraine, her personal and professional spaces. I'm now joined by another New York area neurologist.
I bring to you sometimes a mix of our New Yorkers, Dr. Matthew Robbins, who specializes in the care of people living with migraine, cluster headache, daily persistent headache, and other headache disorders. He's also a leading teacher for other neurologists and a leader in neurology and also the headache specialist communities.
I know him as one of my first colleagues I met in the Bronx when I started working at Montefiore and when he was still there with us, and particularly as an inspirational teacher and leader over the years. Today he helps train students and residents at Cornell Medical Center, and we are happy to have him here on the podcast today to discuss vertigo and headache disorders. Matt, thank you so much for joining me.

Dr. Robbins:
Thank you, Dan. Thrilled to be here with you and the Brain & Life community. Such a great opportunity.

Dr. Correa:
So during our discussion, Deborah drops this term and we bring up this idea of BPPV. So can you explain to our listeners what we're really talking about there and how is that different from just vertigo?

Dr. Robbins:
Sure. Well, to start, vertigo is just a symptom and vertigo really just means the perception of movement of yourself around the world or of the world around you. So vertigo, just like headache is a symptom of many different neurological conditions, but there's certainly a few common vertigo conditions that exist where that is the number one symptom from the condition itself.
And what Deborah was referring to is this condition called BPPV, Benign Paroxysmal Positional Vertigo. It's really a mouthful, but thankfully benign meaning that it doesn't cause any harm in the long run. Paroxysmal means it just happens in short, although very intense episodes. Positional meaning that this vertigo is produced by how the head or the body's position is in space and then vertigo.
And what the cause of this condition is that there are these canals inside of the inner ear that are shaped kind of like circles or semicircle and they have fluid in them. And the way in which the fluid travels in these canals send signals to the nerves that go to the brain to tell where you are in space, based on where your head and body are moving. And if there's something that blocks those canals, it can cause your brain to really have no idea where your body is in space and you can have vertigo.
And in this condition of BPPV, you can have these little stones just like someone could have kidney stones or gallstones, you could have stones in these canals that block the flow of that fluid and really make those nerves go haywire, sending back signals to the brain and feeling this intense episodes of vertigo. And because it's so positional, it means that when you turn your head in a certain way, the stone is going to block up the system all of a sudden and you get these sudden intense attacks of vertigo.

Dr. Correa:
In the past, I've sometimes imagined this idea when we're hanging a frame or something in our house, sometimes you might use that level, and in a way, these three canals are like three different levels and sometimes they can be disturbed and where the little bubble is and being able to tell you what position your body is in.

Dr. Robbins:
That's a great analogy. And I think the brain is very attuned to those types of levels and any minor disturbance or a major disturbance such as a stone blocking the fluid in that canal full of liquid ordinarily can be very disturbing to the brain and then to the person experiencing it.

Dr. Correa:
So sometimes people have heard about these crystals and the canals in your ear and that they may lead to vertigo, but is that the only structure of our brain and nervous system that causes vertigo? Is it all the different syndromes that have vertigo tied back to the crystals and the canals?

Dr. Robbins:
Well, some are, and certainly this condition that Deborah experienced is, but certainly there's the nerve itself that takes those signals from the inner ear and travels to the brain, and then there are the parts in the brain that actually coordinate all these signals that are received.
That's usually in the balance center of the brain and in this part of the brain called the brain stem, which is at the base of the brain, sort of just the level where the brain turns into the upper part of the spine. So the symptom of vertigo can really come from a disturbance in any of those structures all the way from the inner ear, anywhere all the way into the nerve that connects the inner ear to the brain and then inside the substance of the part of the brain called the brain stem.

Dr. Correa:
Now let's go to the idea of the language of when we say vertigo sometimes what that means. My grandmother for years had damage to the nerves in her legs, and for her many times she would describe her challenges getting around walking and a sense of balance as being dizzy. But in reality for her it didn't necessarily mean the same kind of description that you have about vertigo and your sense of space. So how are the differences that you see when people are describing to you what dizzy is to really pick out whether or not it meets our perspective or criteria as neurologists or physicians as vertigo?

Dr. Robbins:
Yeah, Dan, that's a great question and it comes up all the time for us as neurologists when we see patients with dizziness is sometimes it's hard to tell is it from one of these areas of the brain or outside of the brain that we just discussed, or is it from some other problem. Now dizziness generally we like to be clean and break it into two different major causes. One would be a balance issue or something that causes the illusion of movement.
That's what vertigo is. The other might just be dizziness that comes from a lack of blood pressure to the brain because the heart isn't pumping enough blood or the blood maybe doesn't have enough blood cells or enough oxygen or the tone of the blood vessels isn't tight enough to clamp down to bring enough blood into the circulation that gets pumped to the brain and that certainly can cause people to feel dizzy.
Classically, that causes people to feel faint where they feel their vision might gray out. They might feel a sense of disorientation that they might even lose consciousness. And they might lose consciousness either briefly or for some period of time.
That certainly is much more specific to this phenomenon of not and of blood reaching the brain circulation overall. So that's sort of the main distinguishing dividing line we like to do between people who have some perception problem where they feel that they cannot have their equilibrium with movement is off and where they perceive the world is off versus this lack of blood flow to the brain circulation.

Dr. Correa:
We talked about there can be lots of different conditions that have vertigo as a symptom or as one of its syndromic features, and some of those might be headache disorders. So what are some of the other conditions when someone is feeling these features of vertigo that may be related to that presentation or that symptom?

Dr. Robbins:
Yeah, there's a number of conditions that can cause vertigo that could happen in episodes or be constant. Probably you're right, Daniel. The most common cause that we believe we see that should be studied more, but one that we encounter all the time is what's called vestibular migraine. So people are pretty familiar with migraine as a condition that causes headache as a most common symptom.
It tends to affect people of all ages, but tends to come on more when you're younger, can be frequent or not frequent, typically features headache that could be one-sided or both sided, could be throbbing. Often there's nausea or people feel the need to vomit and get sensitive to things like light and noise and smell and other things. Vestibular migraine seems to be a form of migraine where sensitivity to movement is the most common and most prominent symptom.
So we think of vestibular migraine as kind of a variation of migraine, a type of migraine where headache may or may even not be present altogether, but this sort of disequilibrium. Some people have vertigo where they feel there's this really intense perception of movement of the world around them. Some people just might feel very imbalanced and off in another way. But that is typically the number one symptom in vestibular migraine.
Some people with vestibular migraine don't even have headache at all, but if they don't have headache, they still should have other migraine like symptoms. When they feel the sense of dizziness, they should also have light sensitivity, noise sensitivity, nausea. It might happen in episodes that could be triggered by certain environmental things or something internal like a woman's period.
So I think it has a migraine like behavior to it based on how it occurs in episodes, how it has these other symptoms. But that's probably the most common cause of vertigo that we see altogether is this vestibular migraine. In almost kind of a surprising fashion it hasn't even really been an accepted diagnosis until recently, only in the most recent iteration of the International Headache Society classification of headache and headache related problems, only recently has it been entered in as a potential diagnosis.
So you can see that people probably have been struggling with this for years or decades, presumably this has been around for as long as humankind has been around just like migraine has. But people likely have been so undertreated and because it's been so under-recognized, because we haven't even had official criteria until recently.

Dr. Correa:
For our listeners, we've had a few past episodes about migraine, both with guests living with different aspects of migraine disorder and some key experts. So if you want to go back to understand some of those initial aspects and basics about migraine and some of the typical features, please go back and check out those episodes.
We're going to continue this discussion built on Deborah's own experience and some of the discussion about vertigo, vestibular migraine and its overlap. But Matt, we're talking about situations where people all of a sudden feel like very significantly that they may be unstable, may not even be able to walk, and then combined with symptoms that we've talked about with migraine, like they're having difficulty seeing, they have severe pain on one side of their head.
What are some key considerations for help someone who is having these symptoms or if they hear someone around them who are having these symptoms when they need to have a more urgent evaluation or when they should be recording these things and maybe following up in a discussion with their primary care doctor or a neurologist they already see to discuss how their symptoms are changing or evolving?

Dr. Robbins:
Yeah, Daniel, that's a great question. I think certainly when some condition that resembles vestibular migraine first starts, it should be evaluated to be sure that is what is the diagnosis. Because there are scarier medical conditions that could cause both headache and vertigo that kind of resembles migraine together. And I think it does require careful evaluation.
I think you and I would both agree that anyone who's having frequent headache and dizziness and they're really disabled by it, whether it comes on suddenly or really becomes progressive, should seek out care with a specialist like a neurologist like you or I. There's no test for vestibular migraine, same for migraine. It's a judgment call by the person treating that patient to say that there isn't really any other cause that would be likely to explain their symptoms.
It's a difficult concept for patients and people in the community who have these symptoms because it's unsatisfying. You have these horribly disabling symptoms that make you feel awful. You can't walk, you're nauseous. They might happen in episodes that are totally unpredictable or happen really continuously in some unfortunate people, and there's no test that proves you have this. No MRI scan confirms, "Oh, this is what you have because the scan shows this."
So often, it's kind of a frustrating thing for patients because it's simply on the trust of a doctor, hopefully a good one telling you this is likely what you have. Nonetheless, if someone's having these symptoms and it's been happening in episodes over time and there might be certain triggers and in between the episodes someone feels pretty normal, likely it isn't from any scary cause and it is from something like vestibular migraine when they have these symptoms in combination.
It's a difficult condition in many ways because the way in which we manage it really doesn't come from very good scientific evidence. We kind of borrow the evidence from more conventional migraine where vestibular symptoms like vertigo is not present and there aren't really great clinical trials that really have shown that we should be approaching it in any different way than in other forms of migraine.

Dr. Correa:
So in that first onset of a time when this is a new symptom, a new disruption in really severely in your balance or ability to walk or even just of the headache with a change in your sensory perception of the world around you, that instance probably should get a more significant and acute evaluation to help rule out some of the things that we get concerned with and can we can catch those pictures of the brain and further evaluation.
But then it sounds like the more chronic process when it's now it's been, we've ruled out thankfully the big severe, more urgent things that need to be intervened on and then it's more chronic that we should make sure that that person gets to see a specialist to have this more nuanced discussion.

Dr. Robbins:
Yeah, that's right. I think especially the earlier it starts and the more continuous the symptoms might be from the beginning, the more some evaluation is needed. Certainly as you and I both know, people with these types of symptoms, especially in the beginning, often have to come to the emergency department to get checked out to be sure it's not from a scary cause of these symptoms. Thankfully, most of the time it isn't, but on occasion it is and needs to be ruled out, so to speak.

Dr. Correa:
Now, I wanted to go to some of the things that Deborah described that really brought out some of the symptoms. She talked about an experience where she went to on travel to a place that had different altitude and all of a sudden noticed that that triggered some of her vertiginous or vestibular symptoms and even an increase in headaches. Can you talk to us a little bit about how you discuss altitude and other possible triggers with those you care for?

Dr. Robbins:
Yeah. I think it's good for neurologists or primary care doctors or other clinicians who see people to be very open-minded about situational environments that might make their symptoms become much more prominent or provoke them altogether. Certainly altitude, and we know especially high altitude is certainly a trigger for different neurological symptoms.
We know that altitude can lead to some types of changes in pressure inside of the head that can affect the brain and the structures around or inside it. And some people where altitude is such a prominent trigger, sometimes we even preempt the symptoms that could develop if it's a very consistent one with medication to taking in advance of such travel, similar to what people who have known altitude sickness might get, where they might take a medication in advance of such a situation.
So it's very common because of this relationship of altitude to high pressure inside the head to trigger neurological symptoms, especially in someone who's already vulnerable to them. In some people it's a very specific trigger such as Deborah. In some people it might not be a trigger at all.
Triggers are so individualized and it's very hard to predict from one person to the other if they travel, say for you and I from New York City at sea level to go to Colorado a mile high into the sky, whether they're going to experience any symptoms or not. But I think we have to be open-minded and if there is a regular pattern to it, perhaps even consider preemptive treatment for the neurologic condition that's provoked by such travel.

Dr. Correa:
And I've had a few different ways that I've suggested to others on how to keep track of what might be possible triggers, even things that might mitigate or be mitigators of their symptoms. But how do you approach that? What do you suggest to people to monitor and how do they distinguish whether or not just the fact that I had some chocolate today and I had a headache and or vertigo symptoms, whether or not they're related or aren't?

Dr. Robbins:
That's a great question, and it's become a more complicated one as we're starting to understand the biology of these conditions more. For example, we know that in people with migraine and presumably vestibular migraine, there can be what's called prodromal symptoms, which are often called premonitory symptoms. So these are symptoms that seem at face value unrelated to the symptom of their attack like headache or vertigo or dizziness.
That leads to people sort of knowing that the beginning of the attack has happened. But sometimes it leads to people thinking that such a symptom is a trigger for an attack. For example, a lot of people with migraine think that prolonged screen time is a trigger for migraine attacks, but it might be that the migraine attack in the brain has already started and it's led to this light and focus sensitivity that already has been present.
And then because headache develops, people perceive that, "Oh, it must have been the screen time that triggered the headache." But no, it actually was the sensitivity to the screens that reflected the beginning of the attack that started already.
And we have fancy types of what we call functional brain scans, capturing people in their everyday behavior that show that the changes of a migraine attack happen many days even before the attack itself is started, that the patient believes so because that's when the headache started, but these other symptoms are already starting much earlier.
So the same goes for chocolate to your example, Dan, about people think that the chocolate eating has triggered a migraine attack, but often it's the craving for chocolate or the desire to eat chocolate is actually part of the migraine attack itself because migraine attacks may be starting in this part of the brain called the hypothalamus that regulates or leads to stimulation of appetite or cravings or also leads to fatigue or people to yawn uncontrollably.
So people think, "Oh, I'm over-tired. I didn't sleep enough last night, therefore I had a migraine attack." And it might be just a prodromal symptom as part of migraine itself. Likely that's the case with vestibular migraine too, and we just haven't studied it very well yet. The other piece of advice that you alluded to, Daniel, is I totally agree, people should just keep track of their symptoms.
I think it's extremely helpful, especially for women to see if there's a relationship with their periods or other times of the month where they might be vulnerable to attacks, looking at the relationship of their symptoms in sleep. Often weekday versus weekend routines are so different, that that could be a trigger. Daily caffeine intake and sort of other common sense things that could influence migraine of any cause, whether it's sort of the more conventional migraine with headache as the prominent symptom or even vestibular migraine.

Dr. Correa:
And if someone is going to try changing something to see if it impacts their headache or vestibular symptom, how long do they have to do it?

Dr. Robbins:
Yeah. I mean, people ask this all the time, especially "Should we go on this type of elimination diet and how long to do it? And I really love to eat this certain food, but now I'm depriving myself." I mean, we don't want to make people miserable and do unreasonable things, but likely you need to go through at least a month or two months of some change to see if it's leading to some sustained improvement in migraine.
Migraine inherently is a very cyclical condition. So often it has its own behavior where attacks could be frequent in some period of time, and then it could be quiet in another period of time. And often it has this rollercoaster behavior that we can't always predict. So if there's some lifestyle change, the longer someone does it, the better it is to see if it really makes a difference.
But it often is hard to tell. I think us as neurologists or others who provide care to people with neurological conditions, it's really important not to go overboard with some of these lifestyle changes unless it's something that's very obvious and hazardous to their health, like sleep deprivation or people who are shift workers who might have a very erratic sleep schedule, certain diets I suppose, and so on.

Dr. Correa:
But let's go more realistically. Sometimes a shift worker who's living with migraines can't just get a new job immediately. What are some things that when people are in a lifestyle or a situation that they can't change their day-to-day schedule or their kids disrupting their sleep schedule isn't necessarily go away? Are there some modifications and suggestions you discuss with people in those situations that then can otherwise help them with their symptoms?

Dr. Robbins:
Yeah. I mean, sometimes there are common sense things that could be done. Sometimes it's on us to advocate for them to have some type of workplace accommodation if that's an option. So I think we have to be open to that. But often if someone is in the face of some trigger or aggravating factor that's just not realistic to change, then that just might mean they need medical therapy to get their condition better. So often when it comes to migraine or vestibular migraine, what we mean by that is often what we call preventative treatment, some treatment that you use or take every single day to reduce the frequency and intensity of their episodes.

Dr. Correa:
Now, we've talked to that there's been a lot of varying information out there about some of this information, both disorders with vertigo, headache disorders. There can be lots of varying information about things like triggers and things like that. Are there reliable resources that you refer those that you care for so that they can learn more about their condition and symptoms?

Dr. Robbins:
There are. I think a couple of resources that are excellent, the American Migraine Foundation has a lot of different resources that's very searchable to find, especially about migraine and vestibular migraine. Those are very excellent resources. And there have been webinars and recorded events that people can watch to get a little bit more detail about those in that domain.
The American Headache Society has a of different modules for healthcare providers that patients could suggest to their clinician to take a look at, including modules for primary care clinicians that include content about vestibular migraine and migraine overall. And that's been a really fantastic resource for patients and clinicians. And often we have to learn from each other.
I mean, a condition like vestibular migraine is, although it's not new in terms of our belief that people have experienced it since the beginning of humanity, it's newly formulated as a criteria for diagnosis. So lots of people just don't know all that much about it. And the hope is that all these great innovations and migraine overall in terms of treatments will carry over to the better management of vestibular migraine too.

Dr. Correa:
And you've helped push that a lot forward, both writing books and chapters and helping with education of other physicians. What are some of the key areas where doctors and neurologists need to improve our understanding and supporting this community?

Dr. Robbins:
Yeah. I think people with migraine and certainly forms of migraine that are not as well recognized list such as vestibular migraine are often subject to a lot of stigma. And this stigma could be in part related to the sex or gender of individuals with migraine because it disproportionately affects people who are women. People who are underserved also by virtue of their race or ethnicity or their socioeconomic status often just have much worse migraine probably for just lack of access to better healthcare.
And that also seems like a point of stigma that many patients tell us about. So I think one thing is to really be understanding. We have to appreciate that neurological symptoms can be very broad. Vestibular migraine is a great lesson that a condition like migraine might not even have headache at all. And all the patients who've been telling doctors like that for years and have been written off now are kind of having this validation that they have a real condition that has diagnostic criteria that deserves treatments and clinical trials by researchers to investigate.
So I think we have to really as a community, just be very open to what patients tell us. Be good listeners. Let them advocate for themselves, advocate for them if they need accommodations or help in their lives with this, and really consider treating them medically when it's appropriate. I think instead of just kind of writing them off as nervous, anxious people who just feel off because they are from a certain group, I think that just seems terribly inappropriate. We need to just do better for them.

Dr. Correa:
And you've highlighted this way that there can be learning in both directions. What have you learned from the community that you have cared for over these years?

Dr. Robbins:
That's a great question. I think patients have told me to be humble. I think a lot of times what we think is one condition could actually become something else. The relationship between people who have headache and people who have vertigo sometimes can be a little complicated. Deborah Robert's example of someone who had BPPV, this condition that seems totally unrelated to migraine, but then developed vestibular migraine on top of that.
What we've learned is that sometimes having an inner ear issue can later on trigger migraine or vestibular migraine. And before we used to be so pure and keep them separate, but now we realize that often an inner ear issue can trigger a brain dizziness problem such as vestibular migraine. And I think those lessons are really important to bring back to other patients where the treatment of both conditions might need to be utilized when it's not purely just one versus the other.

Dr. Correa:
Now, you've also helped both inspire and educate hundreds of trainees, medical students and residents to become neurologists. Working with them over the years, what have you learned from the trainees, from the younger generation that has made you a better physician as you partner within the care for your patients?

Dr. Robbins:
Well, I think the best way to learn about neurologic conditions is to teach about them because you learn just as much about teaching as you do from those that you teach, who bring you amazing questions, make you really think how you explain complicated concepts in brain science to both them and to patients together.
Often they're the ones who are bringing new insights into a neurologic condition that you think you kind of know pretty well. And I think it makes the experience, including with patients much more rewarding. I love when I have residents or students with me in my clinic or in the hospital seeing patients, including patients who I've known for many years. It just adds to the layers of discourse.
And patients, in my experience, love to have students and residents engaged in their visits because it forces me to be even more clear with explaining to those who are training what the symptoms are. And often we let the patients do a lot of the explaining and they often do a better job than we do because it's just much more real. So I think as we said before, it's really bidirectional. It goes both ways.

Dr. Correa:
Well, Matt, thank you so much for all that you do to help us learn from each other and learn together with our community.

Dr. Robbins:
Well, thanks Daniel, and appreciate this great chance to engage with the Brain & Life community and thanks so much.

Dr. Correa:
Thank you again for joining us today on the Brain & Life Podcast. Follow and subscribe to this podcast so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life Magazine for free at brainandlife.org. Don't forget about Brain & Life en Español.

Dr. Peters:
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Dr. Correa:
You can also find that information in our show notes and you can follow Katy and me and the Brain & Life Magazine on many of your preferred social media channels. We are your hosts, Dr. Daniel Correa, connecting with you from New York City and online @NeuroDrCorrea.

Dr. Peters:
And Dr. Katy Peters joining you from Durham, North Carolina and online @KatyPetersMDPhD.

Dr. Correa:
Most importantly, thank you and all of our community members that trust us with their health and everyone living with neurologic conditions.

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Broadcast Journalist Deborah Roberts on Living with Migraine

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