Nataliia Sanzo RDN, LPN: 0:00

Hello everyone, welcome back to another episode of Hashimoto's Nutrition Rx. I'm your host, Natalia Sanzo, registered dietitian and fellow Hashimoto warrior, and today we're diving into symptoms that so many of you have. We're going to unpack the overlooked connection between Hashimoto's vestibular migraines, chronic dizziness, histamine, nervous system dysregulation and even how food fear and nutrient deficiencies can make these symptoms worse. Today I'm joined by incredible Dr Emily Kostelnik, also known as the vestibular psychologist. Dr Kostelnik, welcome.

Emily Kostelnik, PhD: 0:39

Thank you so much. I'm so excited to be here. Yes.

Nataliia Sanzo RDN, LPN: 0:42

I told you before we went live that this conversation a little bit more selfish for me, because I want to learn as much as I can for my own sake about dizziness and migraines, because once in a while I think we all experience that. So I think everyone should be listening or watching this episode, because at some point they either had all these symptoms or will experience that. So thank you so much for taking the time out of your busy schedule to join us. Now let's start with your story. How did you personally get into the world of vestibular disorder and become known as the vestibular psychologist, and how has living with these symptoms shaped how you helped others?

Emily Kostelnik, PhD: 1:28

today I would say it's been serendipitous. So I was always interested in health psychology, which is really the interplay between medical illness and mental health, and I was actually I had just graduated with my doctorate. I was on my fellowship training in health psychology when I was diagnosed with a very rare vestibular disorder called superior canal dehiscence syndrome, which is actually a physical defect of the ear. I had multiple surgeries. I went on to develop vestibular migraine, as you mentioned, and triple PD postpartum, which we see a lot of emerging migraine issues, also thyroid issues postpartum.

Emily Kostelnik, PhD: 2:07

And throughout my entire experience with kind of my health psychology background and then the lived experience as a patient, I saw how profoundly my personal experience impacted my functioning and my mental health. I also saw a huge gap in education just it was in the medical field and education and treatment for this population, and so I decided to dedicate my career to helping people who experience symptoms like me. Maybe something you don't know about me that I don't talk about that much kind of on Instagram is that I also was diagnosed with Hashimoto's about four years ago, and so I live the comorbidities that we're going to talk about today, but I have been able to very successfully manage it like with lifestyle and diet and now have normal thyroid hormone and no antibodies. So I feel like I've put a lot of pieces together and a lot of work into it, but that's my story in a nutshell.

Nataliia Sanzo RDN, LPN: 3:11

Thank you so much. This is like such a powerful story, especially now that we know that you also have Hashimoto's.

Nataliia Sanzo RDN, LPN: 3:15

I feel like we all feel a little bit closer to you and honestly, I think that's what makes your work is so much more impactful. You're not just coming at this with clinical training, but also with lived experience, and for my audience, many of whom are navigating these almost like invisible symptoms right, it's so validating to hear from someone who truly gets it. Now, for people who don't know who you are, let me give you an official introduction. Sure, so?

Nataliia Sanzo RDN, LPN: 3:49

Dr Emily Kostelnik is a clinical health psychologist specializing in vestibular disorders and also lives with multiple vestibular diagnosis and now we know Hashimoto's. She approaches vestibular recovery through a holistic lens and her personal experience as a patient informs the way she works with her own clients. She's the founder of Rooted Behavioral Education, which provides self-paced virtual behavioral health courses specific to chronic dizziness. It provides one-on-one educational meetings to vestibular warriors worldwide and oversees vestibular mindset coaches. She's also the founder of a private psychology practice called the Vestibular Psychologist, where she provides individual therapy and consultations. Did I miss anything? That covers it pretty well Now in my practice. So many women with Hashimoto's describe symptoms like dizziness, lightheadedness or feeling almost like floaty. Can you help us understand the connection between vestibular migraines and thyroid disorders? What's going on there biologically?

Emily Kostelnik, PhD: 5:01

So I think that scientifically we don't have a firm understanding of the mechanisms. I have my own hypotheses about what's happening, based on my experience, so I can share those. There are some papers on migraine overlapping with Hashimoto's migraine, like the umbrella term, because there's many different types of migraine, so not necessarily specific to vestibular migraine. But my best guess is it's a combination of genetic predisposition paired with nervous system dysregulation, the autoimmune inflammatory component, the thyroid hormone imbalances themselves contributing to dizziness and vertigo, cross-reactivity between the thyroid tissues and various tissues within the vestibular system, like the cerebellum, and then I know we're going to get to this too nutrient deficiencies, high toxic load. So it ends up being this big picture and we have to like unpack things piece by piece. But I see a lot of the same. I would say 90 plus percent of my clients have hypothyroid and they don't know it, or they have hypothyroid and they've never been tested for antibodies, and so this conversation comes up a lot. But there's a huge lack of understanding in the comorbidity between the two things.

Nataliia Sanzo RDN, LPN: 6:16

And I love how you clearly explain some of the things and summarize them. And, like you said, unfortunately we don't know all the ins and outs of this and Hashimoto's. We've known about Hashimoto's for 113 years and the types of treatments and understanding that's available seems like we just found out about this disease a decade ago, but there is such an it's an interesting overlap here. We know that the low thyroid hormone can actually affect cerebral blood flow and brain oxygenation, and especially T3, which is active in the brain, so that reduced blood flow can make somebody feel foggy, dizzy and almost disoriented. And with Hashimoto's being inflammatory, that chronic low-grade inflammation can also synthesize, I think, the nervous system and make you more prone to migraines and vestibular symptoms.

Nataliia Sanzo RDN, LPN: 7:16

So I think so many of my clients feel dismissed when they bring up dizziness to their doctors and they never even hear the word vestibular migraines. I know I haven't heard this word until a few years ago and I have had Hashimoto's and these silent symptoms for, gosh, almost a decade. So we know there is a connection between thyroid health and nervous system. So we're going to unpack that right, just like you said thyroid health and nervous system. So we're going to unpack that right, just like you said. So let's talk about the role of nervous system in Hashimoto's. Can you explain how the nervous system dysregulation might fuel chronic dizziness and how can we start to calm all of this down?

Emily Kostelnik, PhD: 7:59

Yeah, so typically what I see when people come to my practice is, historically they would say, generally I was healthy. They probably had some symptoms like fatigue, maybe they had some subclinical hypothyroid or subclinical thyroid issues that they maybe didn't know about, maybe some gut issues, and then there's some major nervous system insult. That kind of sets all of this in motion and the typical nervous system insults that I sets all of this in motion and the typical nervous system insults that I see are any sort of stressor, so like a relationship breakup, loss of a loved one, a really stressful time at work, emotional trauma, a major environmental toxin exposure and kind of the way that I've conceptualized it is that trauma gets stored in the body and it tends to be a certain type of person that I see too. It's type A perfectionist, very high, achieving.

Nataliia Sanzo RDN, LPN: 8:52

I know.

Emily Kostelnik, PhD: 8:53

Self-sacrificing, difficulty with setting boundaries, difficulty saying no, caretaking, anyway. So a lot of times the trauma kind of gets stored in the body. We develop this hypervigilance, meaning we start to scan, I associate dizziness or I associate these sensations with danger. Therefore my body is not safe. I need to keep scanning for safety. So where we put our attention matters. So when we're telling our brains this dizziness isn't safe, this sensation, this floating, isn't safe, I'm going to keep putting my attention there.

Emily Kostelnik, PhD: 9:24

That engages neuroplasticity. We start to develop a narrative around what it means. So I'm not going to be able to do this, this is what my future looks like, maybe I can't be a good mom or I'm not going to be able to achieve at work. And it develops this just really toxic feedback loop. We end up in rumination, so thinking, the same loops over and over catastrophizing. We tend to avoid movement because that tends to make our symptoms worse. So we end up in this state of chronic sympathetic arousal and cell danger response which we can maybe unpack that a little bit more which leads to hormone dysregulation. So there's a feedback loop through the HPA axis hypothalamic pituitary adrenal there's also the HPT axis, the hypothalamic pituitary thyroid axis, and when these hormones get out of balance, we develop, like you said, that low-grade chronic inflammation.

Emily Kostelnik, PhD: 10:17

We end up with nutrient deficiencies, central sensitization, our bodies become more vulnerable to toxins or things coming in from the outside, to emotional insults, to perceiving bodily sensations as dangerous, and it just perpetuates the cycle. So that's essentially how I see the nervous system pieces fitting together. In terms of how to unravel it. It really requires both a top-down and a bottom-up approach, and what that means is top down is more of the cognitive piece of like how do we interrupt, how do we get you out of these ruminative thought loops, because your body is always listening to the things that you're thinking. And then the bottom up approach is more of a somatic approach of finding safety in the body, which sounds maybe easy, but with people who have been through the ringer in terms of the medical system and been invalidated and been looking for a diagnosis forever and been dealing with these sensations that feel very difficult, finding safety in the body can be a challenge, but it's absolutely essential for kind of breaking that cycle.

Nataliia Sanzo RDN, LPN: 11:23

I love this approach, from top to bottom, like a full body, and I love this that you said finding safety in the body, and I always think you don't have to have gone through a traumatic experience to have troubles finding safety in the body Because, like you said, our body always listens to our thoughts, either good or bad, and whatever you tell yourself, it says it's true.

Nataliia Sanzo RDN, LPN: 11:50

So whatever you're repeating, it's true to your brain, to your body. So I talk about this all the time how this nervous system overload can be truly one of the root causes of so many Hashimoto's symptoms, not just the thyroid numbers themselves. And one thing that I always remind my clients, it's that the healing healing the thyroid isn't just about hormones, right, it isn't just about taking the pill. It's about how safe your body feels, and I love that you brought it up.

Nataliia Sanzo RDN, LPN: 12:26

Chronic stress, inflammation, poor sleep, blood sugar crashes I'm not about nutrient deficiencies, but I also want to touch on blood sugar crashes that can also keep your nervous system in this like fight or flight mode that just alone can cause dizziness.

Nataliia Sanzo RDN, LPN: 12:44

Sometimes a lot of my clients well, including myself experience that almost on a daily basis because I run long hours here in the clinic, so sometimes I may miss a meal and as soon as I get up I feel dizzy. If you continue to do that, if you don't pay attention to when you're fueling your body and how you're fueling your body, you're dysregulating your nervous system and causing which will cause this chronic low-grade full body inflammation. So things like I mentioned consistent blood sugar grounding meals, making sure that we're enjoying them mindfully. Getting outside first thing in the morning and reducing histamine load, which I hope will get to it, can really support the nervous system, along with other things that we mentioned, so I don't think we need to invest $300 in the nervous system. Course right. I think we need to find consistency and nourishment in our daily activities that we're already doing, and so I think it's empowering to know that we can actually train our nervous system to feel safer and more stable in our body Definitely, and I think a lot of it is.

Emily Kostelnik, PhD: 13:59

I think people want tools and tricks and those things can be important. And people ask me all the time if I only have five minutes a day to regulate my nervous system, what should I do? And I always say, first of all, the problem is that you only have five minutes a day. But the other problem is what are you doing for the other 14 hours in the day, because that is more impactful. The way that you're interacting with the world, the way you're rushing around trying to multitask, doing a million things at once, eating quickly while you're standing and doing other things, all of that stuff is dysregulating the nervous system. And so how, just how we move through the world, in and of itself, I think, is more important than any specific like tool, if that makes sense.

Nataliia Sanzo RDN, LPN: 14:47

I love that you actually put us on the spot. I asked people who's. Oh, I only have five minutes for self care. Yeah, I do. But for those of us maybe who have five minutes in a day, okay, one or two or five things that we can do, yeah, or what would be the most important thing.

Emily Kostelnik, PhD: 15:08

So I would say the most important thing to start just throughout the day, try slowing down by five or 10%. Just notice how you're rushing around and doing thing to thing, never really being fully in the moment, always doing something but thinking about the next thing. We're meant to be in the moment and to savor the moment and experience the sensory, taking the senses of that moment. If I had to pick one tool or one thing, it would probably be breathwork, because I find that to be one of the most powerful things, and we take 20,000 breaths in a day, and so that's a great opportunity to start to train like your diaphragm, to start getting a better workout rather than chest breathing, for example. So I would say breathwork is one of the most foundational things.

Nataliia Sanzo RDN, LPN: 15:57

Do you have one exercise, that kind of that you personally use or implement when you're stressed out and you're like, okay, I'm going to take 60 seconds to just calm myself down, is there? A certain one, two, four count, or is?

Emily Kostelnik, PhD: 16:12

there any? My favorite is probably the physiological sigh, which is where you breathe in through your nose. So you breathe in pause and you breathe in again and then breathe slowly out through your nose. So you breathe in pause and you breathe in again, and then breathe slowly out through your mouth.

Emily Kostelnik, PhD: 16:33

I already feel less stressed out. I hope I'm not breathing into the microphone. So the longer exhale is what activates that parasympathetic activation that rest and digest the vagus nerve. The vagus nerve is very complicated, much more complicated than people think, but it is involved in that parasympathetic activation which is what puts us more into a place of repair and recovery.

Nataliia Sanzo RDN, LPN: 16:57

And how often would we need to do these breathing exercise per day?

Emily Kostelnik, PhD: 17:02

So I tell people to do them at least three times a day and then use it in moments when you're feeling particularly activated. One of the biggest mistakes I see people make is they do it only in moments of really high stress, which is problematic for a few reasons. Number one it's a skill that you have to learn and you have to build muscle memory for it. And number two, if I only do this breath work when I'm in a moment of intense stress, my body associates breath work with stress, which is what we don't want. So we want to do it throughout the day to lower our baseline of arousal If we're assuming we're in this state of fight or flight, which most of us are and so our bodies associate that with common safety, and so we build efficacy and we feel effective at using it in moments of more activation.

Emily Kostelnik, PhD: 18:09

You know I never heard anyone brought up this point that if you only use breath work during high stress situation, your body associate that stress with the high stress situation. Because I the only one. People come to me all the time they're like, oh, breath work, I've done this before, I know how to do it. It doesn't work for me and I was like let's start over and maybe I can introduce it in a little bit of a different way, but it consistently is one of people's most favorite tools.

Nataliia Sanzo RDN, LPN: 18:28

So can I retrain if I have been doing it all wrong my breath work? Can I retrain my body to not associate breath work with high stress?

Emily Kostelnik, PhD: 18:37

Absolutely. Our brains are super plastic. Undoing things like that is actually not that difficult. It just takes repetition and intention.

Nataliia Sanzo RDN, LPN: 18:46

I'm going to start doing that today, right after this enjoyable conversation. I'm going to do my breath work before high stress situation, right.

Emily Kostelnik, PhD: 18:56

Yeah, yeah. And one other thing that I introduce going to do my breath work before high stress situation. Right, yeah, yeah. And one other thing that I introduce people to is something called the pre-MAC principle, which is when you pair something new with something that you already do, you're more likely to remember to do it. So if I brush my teeth twice a day, I might pair my breath work like before or after that. Or if I eat three meals a day, I might pair it before or after that, so it becomes part of the routine. So I learned to pair it with something that I already do, if that makes sense.

Nataliia Sanzo RDN, LPN: 19:21

That's such a great point. This way, you never have to remember or put it on your calendar what comes after your breathwork or before. So see, the little tips like this, I think, are the most valuable and will make a big difference. We're not relearning something, we're just learning hacks. Little hacks that will change, little tweaks. Yes, there you go. Now let's talk about something big in our life toxins. What's the deal with environmental toxins and how they might contribute to vestibular symptoms? Is there any overlap with what we see in autoimmunity, like Hashimoto's?

Emily Kostelnik, PhD: 20:02

So this is a topic of great interest of mine more recently and something that I've personally done a lot of work with. I don't have a big database. I wish I had all hundreds of vestibular migraine patients and all of this testing. I don't. I have all hundreds of vestibular migraine patients and all of this testing? I don't, but I'm starting to put patterns together. I would say I can't personally think of one person in my practice who has pursued testing to look at toxins so mold, heavy metals, pesticides, plastics, etc. Who hasn't had elevated levels. And someone's argument to that might be everyone has elevated levels.

Emily Kostelnik, PhD: 20:36

We're exposed to these things all the time, true, but I think that our genetics can load that gun. Dysregulated nervous system can pull the trigger on making us more vulnerable. I'm actually working with some colleagues right now on looking at genetic pathway variants in vestibular migraine, so looking at inflammation, detoxification, methylation, dna damage, which I feel like are putting us at risk for not only developing vestibular symptoms but maintaining them. So I would say there's a huge toxic load connection between toxins and vestibular symptoms. And then, of course, we have the comorbidity of Hashimoto's. I don't personally see people like who singularly have Hashimoto's. It's always together with a vestibular disorder, so I don't know if you have any other comment on that, but I can say from my personal experience with practicing toxin avoidance and being more careful about my environment it has had a huge impact on both how I feel like from a neurological perspective and my belief about my thyroid's kind of ability to recover from that.

Nataliia Sanzo RDN, LPN: 21:45

Unfortunately or fortunately, we can't put people in isolation. People with Hashimoto's expose them to toxins and see if their dizziness gets worse or better. So yeah, fortunately we can do that. But when I work with my clients, it's usually a two three months process. I do it's a minimum of two months coaching process with me. So when we address everything from decreasing toxic load, improving diet, managing thyroid medication, decreasing stress and everything that goes with just lifestyle approaches and dietary approaches, we see improvements in dizziness, migraines and all that stuff.

Nataliia Sanzo RDN, LPN: 22:29

Now can I pinpoint what helps? Not really. I think it's a full body approach. I can never say, oh, somebody, for example, avoided eggs or we eliminated eggs and the migraines went away. You can't say that, although I had one client in the last I've been doing this for over eight years I had one client who had migraines after eating eggs. This is the only instance. So by removing eggs she got rid of migraines. Not everybody with Hashimoto's need to try that out. I think it was just one and done case. So unfortunately I can't pinpoint what helps. It has to be this comprehensive approach, including nervous system regulation. Yes, now how do we decrease the toxic load? Because there's so much out there, it's a lot.

Emily Kostelnik, PhD: 23:23

It's so much. I think my approach to it is harm reduction and not perfection. I'm very cautious about the messaging I put out, how I talk to people about it. I personally feel like I have been harmed in some way by Instagram scrolling and a lot of fear mongering, and I think that, in and of itself, dysregulates your nervous system more and can make you feel more paralyzed about what to do.

Emily Kostelnik, PhD: 23:50

So, in terms of I think there's different categories. I think there's like indoor air quality, which might be things like looking at water damage. It might be air purifiers, dehumidifiers, keeping dust low, leaving your windows open when, like, the weather's okay outside. Then there's like the beauty and cleaning products, and my approach to that is use up what you have and then maybe replace things as you need new things. Up what you have and then maybe replace things as you need new things. There's food and food storage. So then we're looking at plastics and how we're heating things up and the types of foods that we're having, and we have to also keep in context like what do people have access to? What are their resources? So I think it's an incredibly complex conversation that has to be personalized and tailored to the person, but my general approach, my general messaging around it is reduction and not perfection. And what are some small areas that we can start with?

Nataliia Sanzo RDN, LPN: 24:45

I think that it's so helpful that you mentioned all of this, because it's a good reminder that it's not about fear or living in the bubble. It's about being aware of what you're exposed to and gently lowering the toxic load as you go. Just like you said, use up your cleaning supplies and then, as you replace them with a better option that you think is the better option, it doesn't have to be all just water and vinegar. There are cleaning supplies that may work better, that are still natural and not toxic. Right, you don't have to make your own detergents, you don't have to become so crunchy and, by the way, I just learned that word recently on the internet Crunchy is someone who basically, I would say, lives in the bubble, and I don't want to offend anybody, but it's a person that lives in the bubble and is afraid of everything and makes it their own detergent or hair shampoo or sunscreen and all that stuff. I honestly don't have time or capacity to even learn what that entails.

Nataliia Sanzo RDN, LPN: 25:57

So, to me, I love that you said reduce the harm, stay away from the perfection. So, to me, I always want to do the best that I can in this situation. If I'm traveling and I don't have my homemade sunscreen. That's a joke. I'll buy regular sunscreen because I don't want to get burned. I'm very fair-skinned. We need to eliminate this fear of oh my, god forbid I do something or expose myself to toxins, because our bodies are designed to eliminate toxins on a daily basis through our liver, kidney, urine, sweat and poop. So we have all these outlets that are helping us detox daily, and I actually have a full video that I put up on YouTube I don't know, maybe six months ago, talking about how to detox safely when you have Hashimoto's. And it all talks about how to improve sweating, because a lot of people, including myself, have reduced ability to sweat with Hashimoto's, and I actually learned about it not from textbooks, but looking at myself, I'm like why am I leaving the gym looking the way I came into the?

Emily Kostelnik, PhD: 27:11

gym.

Nataliia Sanzo RDN, LPN: 27:11

I work out hard. It's just we don't sweat. A lot of people with Hashimoto's don't sweat as much as we should. So things like natural detoxing and how to poop right and the stool consistency and how often you should pee and what your pee should look or even smell like, I think those are the best detoxifying approaches we can and should implement. After we I love using your term reduce the harm. Yes, such a good reminder. Don't be afraid to be exposed, just minimize the exposure. Now let's talk about. We'll switch gears and talk about nutrition, maybe blood sugar, but many of my clients are actually nutrient depleted, especially in magnesium, b vitamins and vitamin D. Can you share what in terms of nutrient deficiencies that could play a role in dizziness, especially for those with chronic illness?

Emily Kostelnik, PhD: 28:11

So all of the things you mentioned are things that I routinely see as well. I would add iron and zinc to that list as well. Minerals as well. So we know like iodine and selenium are really important in thyroid. Also, nutrients involved in mitochondrial function, which I feel like the mitochondrial function is at the root of a lot of this too. So things like CoQ10, carnitine, creatine.

Emily Kostelnik, PhD: 28:34

The problem is, people will come to me and I'll say has anyone looked at your nutrients? And of course no one has, and so we go down that path together. One problem I see, and I wonder if you can relate to this people in this community, myself included, are very sensitive and I know we're going to get into the kind of histamine component, and kind of upregulating these systems with these nutrients can backfire because it can cause histamine reactions and other sensitivities, and so I find we have to go very slowly with things. But in general I would say it's usually not one thing. People are usually nutrient deficient pretty across the board, and that's exacerbated especially for people like postpartum is one of the areas I see it to be the most problematic.

Nataliia Sanzo RDN, LPN: 29:23

I couldn't agree more. So many of my women that I work with are running on empty magnesium, b12, vitamin D and I'm glad you mentioned iron. They're all suboptimal levels. So they may not be deficient, but there are suboptimal levels for optimal health, right, because that's what we always look at. Because we know that magnesium is needed for vestibular nerve signaling.

Nataliia Sanzo RDN, LPN: 29:48

B vitamins, or especially B12, are critical for that myelin and brain energy. And of course, vitamin D plays a regulatory role in the immune system. We know that. And neurological health and fun fact or sad fact that 85% of people with Hashimoto's are deficient in vitamin D. And replenishing vitamin D levels with supplements, levels with supplements, sunlight or even vitamin D shots sometimes actually helped improve Hashimoto's related symptoms but also slow down the progression and aggression of autoimmune disease.

Nataliia Sanzo RDN, LPN: 30:27

I often run labs and see like normal serum of B12 and everything else but low functional markers in histamine, like MMA and homocysteine, and clients are still feeling dizzy, exhausted, anxious. So once we replenish those nutrients especially with, of course, as a clinical registered dietitian, I use food first strategies plus targeted supplements, so we see real improvements after replenishing. So I think we cannot overlook the testing and then replenishment because we can tap our worries away and regulate our vagus nerve as much as we can, but if we're deficient in those nutrients, there's nothing you and I can do. You know that our work will be limited, so I think it has to be a comprehensive, different, comprehensive approach. Now let's talk about histamine. You mentioned that histamine intolerance often shows up in both vestibular disorders and autoimmune conditions. What's your take on the role of histamine in dizziness and how do you help your clients to go through this?

Emily Kostelnik, PhD: 31:42

Histamine is tricky because we don't want to completely downregulate it to zero. We need some. It's very important to part of the immune system. It's an excitatory. It acts as an excitatory neurotransmitter. The thing that I see a lot is people with these histamine overloads but not making the connection that it's histamine, because they might not have the traditional runny nose, sneezing, watery eyes. It's much more neurological. So the thing I see a lot with people is not realizing that there's a histamine component. First and foremost.

Emily Kostelnik, PhD: 32:20

A lot of people go and try to do these elimination diets on their own. So low histamine is one that's at the top of the list that people will try in the vestibular community and I have like a love-hate relationship with it in that it can be an extremely powerful tool. However, I have seen it done incorrectly to the point of harming people. So I think elimination diets can be hugely helpful when they're done under like supervision, like with someone like you. My problem with it is I see a lot of physicians or people online publishing these food lists and saying try this, and then there's no supervision. People end up with severe food anxiety, more food sensitivities, their gut gets completely dysregulated and I've seen people develop eating disorders from it as well, and so I think we have to be really cautious around. Who is the right candidate to use the tool and do we have the right supervision for the tool? And I think the question too comes down to do we have trouble breaking down histamine? Is it more of a histamine gut histamine intolerance situation? Are we dealing with mast cell activation syndrome and figuring out why do I have such a high histamine load? Is it a primary histamine issue? Is it secondary, because I'm being triggered by toxins or a history of trauma, or the foods I'm eating, or whatever it is? So the histamine piece can be hard to unpack.

Emily Kostelnik, PhD: 33:51

I think my role as a psychologist is partnering with people to get them the education they need of. Could this be something that's impacting me? How do I connect them to the right person to work with them, like a dietician, for example, and then checking in? How is it going? How's the elimination going? Are you reintroducing? How are you feeling towards food? Are you is your I don't know someone with a history of OCD? Is that being triggered? Is your perfectionism triggered? How are you doing with reading food labels? So checking in over time and making sure just to keep a close look on it and then potentially collaborating with whoever it is that they're working, that's, making more specific dietary recommendations.

Nataliia Sanzo RDN, LPN: 34:30

I always say, treating Hashimoto's and all these comorbidities and symptoms takes a village and by village, all kinds of different professionals, including endocrinologists, a psychologist, a registered nurse, a dietician, because truly it's so complex and I think your explanation makes so much sense and I think a lot of people will have an aha moment hearing all of this, because histamine issues can be so sneaky and often misunderstood. I am sometimes I read about it every day, trying to educate myself, but it's still so confusing and it manifests itself differently and the testing is still poor out there. It's not all black and white, but when you're constantly feeling dizzy or lightheaded, it's worth exploring how histamine is interacting with your nervous system and immune system. But I could not agree more that it's so easy to fall into this cycle of over-restricting and I always tell my clients food is supposed to nourish you, not scare you, and sometimes the fear is more inflammatory than the food itself. Right, exactly, and for me as a registered dietitian, the goal is always the end goal is to get back to normal eating. If you want to follow a gluten-free diet, dairy-free, soy, egg-free, whatever, let's do that. I'll start you there. We'll build a nourishing meal plan based on their restrictions. But as we're healing our gut with supplements like L-glutamine and butyrate those are my staples in my practice as we heal our gut, we should start reintroducing the food. The people should not have a reaction to it. If there's still a reaction, then we need to test, maybe for non-celiac gluten sensitivity or celiac itself. So normally, like I said, the end goal is to have a normal diet.

Nataliia Sanzo RDN, LPN: 36:32

Now you mentioned you do not have TPO antibodies. At the beginning of the podcast you said I have flash photos. My TPO antibodies are non-detected or low. Are you following? And if you don't want to share, don't share? But are you taking any specific supplements that you feel are working for you?

Emily Kostelnik, PhD: 36:54

That's a very complicated question that would take a very long time to answer. The reason I'm so passionate about the elimination diet piece is because I'm one of those people that like went from doctor to doctor and like, try this, no, do this. And I never reintroduced foods, so my diet was extremely limited. I had very bad food anxiety so there was a period of time when I was I can't even list all the things I didn um meat and non-starchy vegetables and fruit and since then I have reintroduced tons of things, including grains. I'm still gluten-free. I've dabbled in dairy a little bit and that's been okay, even with grains. My antibodies haven't spiked.

Emily Kostelnik, PhD: 37:36

At some point I probably will try to reintroduce gluten. I know that's a really hot button topic that some people are like if you have autoimmunity, never again can you have gluten or dairy, and I think it's more individual than that. As far as supplements the ones you mentioned I'm not on glutamine, but butyrate, definitely probiotics, things to help calm histamine stuff. I have a big fungal component antifungals, lysine, phosphatidylcholine. Ginger is really big for me, really helpful. I'm trying to think about that.

Nataliia Sanzo RDN, LPN: 38:09

I do a lot of ginger teas, or if I do green tea, I slice just a fresh ginger root into my tea and that helps a lot. It's just bloating and digestion.

Emily Kostelnik, PhD: 38:21

Yeah, Fun fact for ginger there's one study that showed that ginger 500 milligrams of ginger extract aborted a migraine attack, as well as sumatriptan. Wow, and I found it's my first go-to if I feel like a vestibular migraine attack coming on. It's the first thing that I do and some people don't tolerate it. They get good symptoms from it, but it's hugely helpful for a lot of people, I think because of the antihistamine, anti-inflammatory impact.

Nataliia Sanzo RDN, LPN: 38:53

Now is there a difference between regular migraines that I might get and vestibular migraines?

Emily Kostelnik, PhD: 39:00

So it falls under the same umbrella. I think the thought is that it impacts different parts of the brain. So there's classic migraine that might have, like the one-sided head, pain, light sensitivity, sound sensitivity, ocular migraine, hemiplegic migraine still treated as migraine. So, like the same migraine, prophylactic and abortive medications are used despite, or no matter what type it is.

Nataliia Sanzo RDN, LPN: 39:32

Last year I developed migraines Like I've never had any kind of problems with my dizziness, never had a problem Just occasionally if I don't eat on time, and just my nose down that kind of dizziness. But last year I started waking up with migraines and I was like, is this a headache or is this migraine? I didn't even know how it felt, but then the next day it would start at lunchtime and the next day it would be like after mealtime. So of course I started doing an elimination diet. I would remove just one kind of food or food group that normally triggers migraine and see how I react, because elimination diet is the best way it's still a gold standard to find out what foods you're sensitive to. There's no test, there's no blood test that can tell you which foods you're sensitive to. There's no scientific background behind those blood tests. The gold standard foods you're sensitive to. There's no scientific background behind those blood tests. The gold standard, like I said, to determine your food sensitivity is to eliminate that food for about a week or two and then reintroduce it back. So I did all of that.

Nataliia Sanzo RDN, LPN: 40:37

After four months of having these migraines, I went to see my doctor only because I had to cancel a client here at the office because I couldn't function. What is happening? So I went to my doctor and I'm like please run all the blood tests, everything you can possibly do, and do a heavy metal panel. And he's you're not exposed to heavy metals, you should be fine. You don't need that panel because it's more expensive to run, it's not normal, it's not covered under insurance and my heavy metal panel came back high.

Nataliia Sanzo RDN, LPN: 41:12

I had toxic levels of mercury as soon as we addressed that the heavy metals and we did not do chelation therapy, which I'm so grateful. Because I work and live in this environment, I know better. I know there are approaches that you can do naturally to detox from heavy metals. So I did all of that and my migraines went away. Like it's not easy, I know. I was so happy because I thought what is this? Am I developing another autoimmune disease that's leading to it? But it was just Eric, just heavy metals. So again, testing, not getting one, just yeah, just heavy metals. Now I know you're releasing a new course this fall. Can you give us like a sneak peek into what that program includes and who's that the best suited for?

Emily Kostelnik, PhD: 42:09

Yeah. So this is the first time I'm like publicly talking about it so hot off the presses. It's going to be called Back to Balance the whole person approach for chronic dizziness and it is the. It's essentially what I've learned over the past many years with my vestibular disorder and studying this and working in the field. It is the biopsychosocial, spiritual, environmental approach. I think a lot of times those last two pieces are missing and I think education itself is a hugely powerful intervention. So I'm going to talk about all the reasons why you might be dizzy, ranging from mitochondrial dysfunction and cell danger, response to trauma to central sensitization and negative plasticity. I'm going to cover inflammation, the role of the nervous system, regulating the nervous system, personal identity and chronic illness, alternative therapies, what to do in certain situations and support people along the way. So that's to come, probably in September or October. I'm working very hard behind the scenes. It's a tremendous undertaking but I'm really excited about it.

Nataliia Sanzo RDN, LPN: 43:14

And as soon as you have a link to that course, we'll publish it. It will be published on YouTube, Facebook, all the platforms and when it is published, we'll add that link September, October. So I'll keep an eye on that because I want to update our community with the latest links, latest information, and I'm excited to look into it as well. Thank you, and I love that you're creating something so comprehensive and, honestly. The fact that it is coming from someone who lives with these symptoms and work with clients every single day makes it even more valuable. So I know so many of my listeners will want to check it out. I have no doubt about it. Thank you Now for someone listening today who has Hashimoto's and keeps experiencing this dizziness, or unexplained dizziness. Where should they start? What's one thing you said from when we finished this conversation? Where should they go or what should they do to get on this journey?

Emily Kostelnik, PhD: 44:18

Yeah. So I'm a big fan as I mentioned the whole person I like to marry conventional medicine with more integrative and functional approaches. I think it's always important to have like a vestibular workup to rule out other things. So that might look like balance testing, it might look like imaging. So the kind of first stop for that would be either an ENT or a neurologist and I'll talk about those kind of separately. So an ENT is an ear, nose and throat doctor or otolaryngologist, but you want someone who specializes in the ear. So that would be an otologist or a neurotologist or a vestibular neurologist or a neurologist who's a headache specialist. So, like all of those people which I'm saying, all of those people which I'm saying all of those people there's not that many of them Like it can be hard to find people when they have long wait lists they're going to be your best bet in terms of saying is this vestibular migraine? Is it something else? Is it Meniere's disease? Is it triple PD? Can we rule out things with imaging? From there, I would say the most foundational people that are going to be on your team vestibular physical therapist and someone like a psychologist or a mental health provider. I'm a huge fan of dieticians as well, so we'll throw you in there as well. So once you rule out and get a bit firmer sense of diagnostics, that's when the recovery can start. People get confused too. They're like do I have vestibular migraine, or do I have heavy metals, or do I have mold, or do I have gut dysbiosis? And the way that I describe it to people is it's not either, or Vestibular migraine is the cluster of symptoms you're describing that we can label vestibular migraine so that healthcare providers and people can communicate with one another and we have an idea of what you're talking about. But you might be being triggered by these other things. So if we can address these triggers, we can lessen the symptoms and manage it better, if that makes sense In terms of one takeaway to make people feel more balanced super quick physiology.

Emily Kostelnik, PhD: 46:25

Your vestibular system is your eyes, your inner ear and proprioception, or touch sensation. When you develop dizziness, a lot of times the sensory integration of those three things gets out of balance. So a lot of times our brain starts preferencing vision and you can develop things like visual vertigo, visual dependence. So one thing that can be tremendously helpful to bring back things into balance is to focus on proprioception what that would look like is I'm sitting here in this chair. Maybe I'm feeling a little floaty or feeling some sense of movement. I'm going to probably with my eyes open, maybe with my eyes closed, if I'm comfortable focus how it feels to have my feet on the ground, how it feels to have my back against the chair. A lot of times that sensation comes up when people are lying down at night and their vestibular system is very fatigued after the day, focusing on how it feels to have my body lie on the mattress. So you're teaching your brain to focus on a sense of balance and to help reintegrate that proprioceptive input, if that makes sense.

Nataliia Sanzo RDN, LPN: 47:29

So would yoga or Pilates be a good exercise to incorporate for these kinds of symptoms, because I feel like those are grounding exercises, that you connect your body, you're really thinking what you're doing instead of just running or just lifting heavy weights and just being in this.

Emily Kostelnik, PhD: 47:47

Yeah, I think they can be great. I think it would depend on where the person is on the continuum of severity and functional impairment. If someone is having vestibular migraine attacks every day, I probably wouldn't recommend they do yoga with like downward dog because that could trigger a migraine attack quickly. So we want to use like a pacing approach. But I like where you're going with in terms of getting more into the body. You also sometimes have to be careful with that, depending on the level of trauma history, because the body can feel like a very unsafe place for people with a more extensive trauma history.

Nataliia Sanzo RDN, LPN: 48:25

But in general, yes, focusing on more calm, intentional body mind connection, and I think I have a podcast that says best workout for Hashimoto's and there's no such thing. It's whatever works for you. If you love HIIT, go do that. If you love lifting weights and nothing else, go do that. But be mindful of other workout that will bring more than just body shape or weight loss.

Nataliia Sanzo RDN, LPN: 48:56

Because, we need to ground, to go, take our shoes off and go barefoot. And grounding. It doesn't build the muscles, but it builds something maybe even more important. It's that body-mind connection, relaxation, system regulation, because the older we get, the more in my personal experience, the more I realize I need to take care of this body. This is the only thing that I have that will take care of me.

Nataliia Sanzo RDN, LPN: 49:23

First, I was taking notes during this conversation, so I hope other people were doing the same thing, and I love that. You summarize everything so beautiful and it's such a grounding way of looking at things and sometimes we think that we need a 30-step plan or a full protocol, but it really does start with one small shift. It's that feeling of safety in your own body and knowing what works for you. Thank you for bringing up to light some of the things that I actually never even heard of. For me, this was very enlightening and I hope listeners and if people are watching it felt the same way. Dr Kostelnik, again thank you so much for dedicating a full hour to us. This was amazing the great information and very actionable and practical steps that people can take today to start feeling better. So thank you so much.

Nataliia Sanzo RDN, LPN: 50:24

Of course I was so happy to be here, yes, and maybe we'll jump on another YouTube video or podcast, because there is so much to uncover with nervous system regulations and maybe we'll need to talk about other testings that we do. I would love to hear what you test in your practice. And, of course, histamine we can talk about histamine for the next three hours. So I would love to hear what you test in your practice. And, of course, histamine we can talk about histamine for the next three hours. So I would love to have you for another episode when time is right. Thank you, thank you so much and bye eve rybody,