HRV and Fibromyalgia: What’s Your Heart Rate Variability?

Grey background on top 1/2 with red heart and white EKG lines going through. Title font in black: HRV and Fibromyalgia: What's Your Heart Rate VAriability

As you probably have guessed, I am not a trained medical health professional. What I am is a mom, a mimi, a retired teacher, a lover of nature and of music, as well as, someone living with chronic illnesses. I share my journey to provide some insight and hopefully ideas that may be helpful to others dealing with similar issues. Always, consult with your doctor before trying anything new.

As is the case for every person living with Fibromyalgia, we were diagnosed by our symptoms and process of elimination. This means we have pain all over the body (also referred to as widespread pain), sleep problems, fatigue, and often emotional and mental distress lasting for more than three months. We also have undergone several tests, exams, and imaging to rule out other issues.

What this means is that all our tests, imaging, and physical exams give no indication that something is wrong, yet we experience symptoms that are very real and interfere with our daily functioning. For me, that interference was so severe that I had to leave my teaching career well before I had wanted to.

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Heart Rate Variability (HRV)

In an attempt to better my pacing and monitor the quality of my sleep, I purchased a FitBit Charge 3. During the first six months, I had the premium app option. I was able to see the change in my heart rate after meditation or after a stressful phone call. It was towards the end of my free time, that I found my HRV measurement.

I had never heard of HRV, so I looked into it. Googling, Healthy heart rate variability by age, I found an article on WOOP.com (a similar device to a Fitbit). They indicate that for a woman my age an average range should be anywhere from 30s-50s. I range 15-25… That got me wondering. Is this the ONE physical indicator that shows I’m not well?

One Doctor’s Use of HRV to Help Treat Chronic Pain

It was on LinkedIn that I met Dr. Pete Lillydahl. He posted several articles about chronic pain and HRV. He also noticed my approach to wellness, rewiring my pain-filled brain. Through those common concerns, we began a conversation.

I’ve been very fortunate in this regard. I’ve met several people online that have helped me progress in my wellness journey, and Dr. Lillydahl has opened my understanding as to what my HRV numbers mean and has also given me hope that I am on the right path to improving the function of my Autonomic Nervous System (ANS) through the brain training I’ve already started.

Grey and red background. Grey on the top half features a red heart with white EKG heartbeat lines. WHAT is Heart Rate Variable? is in black font.

I know that the PFL Community will be intrigued by all that Dr. Lillydahl has to share on his use of HRV in treating chronic pain and illness. But first, let me tell you a bit about him.

He was born and raised in Milwaukee, Wisconsin. After graduating from Duke Medical School,  Dr. Lillydahl worked at a clinic in Kenya for 6-months and then spent the next 5-years in training for a career as an Otolaryngologist – Head and Neck surgeon, better known as an ear, nose, and throat doctor. He practiced ENT in Boulder, Colorado for the next 36-years, retiring in 2016 to work on the Easeday Migraine app which was released last January in the Apple app store and soon to be released in Google Play.

A red background with a heart frame centered, featuring Pete and his son standing in front of the Rocky Mountains.
Dr. Pete Lillydahl and his son (Easeday collaborator) in Alaska.

Thank you, Dr. Lillydahl, for agreeing to help me and the PFL readers understand what Heart Rate Variability is and how it can be a helpful indicator to monitor our health.

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How did you become interested in heart rate variability and chronic pain?

While practicing medicine in a multispecialty group, it was hard not to notice that patients who had a stress component to their illness were bounced around from referral to referral and test to test without anyone addressing the underlying mood issues.

I had been exposed to biofeedback in the 80’s when Boulder was a national center for its development. Over the years, biofeedback would be well-shown to help such illnesses as migraine disease, tension-type headaches, and TMJ syndrome, but insufficient reimbursement kept it on the back burner. 

When heart rate variability biofeedback became popular in recent years as an athletic training method, its advantages over other forms of biofeedback for treating illness were clear:  Heart rate variability biofeedback requires just the camera of a smartphone and an accompanying app. With no extra hardware, people with chronic pain conditions can treat the neurological imbalances that often drive chronic disease. And they can do it in the comfort and privacy of the home.

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What is your treatment approach?

A headache is not just a headache – it’s an indication of a whole-person problem. As with any of the chronic pain syndromes that so often accompany migraines and headaches, the most successful treatment plans take a biopsychosocial approach.

So-called “integrative plans” use not just medications, but whatever logical and evidence-based therapies that work best for any particular individual. Behavioral therapy, lifestyle modifications, sleep optimization, appropriate exercise, hands-on physical therapy,  massage, and many other scientifically backed methods may all be part of the plan.

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What is Heart Rate Variability (HRV)?

To simplify, heart rate variability is a measure of your body’s relaxation response. Put slightly differently, HRV  is a measure of the body’s resilience to life’s inevitable challenges and stresses. Over months or years, higher HRV scores indicate better health. 

We’ll get deeper into the science later, I’m sure, but I was reminded of a newspaper cartoon last week that showed two scientists in a lab, with one asking the other, “Why can’t you discover anything that’s easy to explain on a talk show?”  

A Wall Street Journal Cartoon: Line drawing/black and white of two scientists in a lab talking: "Why can't you discover anything that's easy to explain on a talk show?"

That’s been the problem with popularizing heart rate variability as an objective measure of both wellness and illness. Fortunately, public awareness of HRV is growing. 

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How is HRV measured?

HRV is calculated from detecting your pulse or heartbeats, but HRV is not simply how fast your heart is going.

When you breathe in, your heart beats faster. When you breathe out, your heart beats more slowly.  Your HRV score represents that CHANGE in heart rate during a respiratory cycle. Your heart rate variability reflects your body’s ability to put the “rest and digest” brakes on your “fight or flight” reflex after an emergency has passed.  Again, high HRV is good.

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For those living with chronic pain, what role do you think HRV might play?

You can use your HRV score to monitor your overall physical and mental state of health. In addition, doing heart rate variability biofeedback-assisted relaxation training can increase your HRV scores over time. In other words, you can use HRV to increase your resilience to stress.

High heart rate variability correlates with good cardiovascular health, longer lifespan, less inflammation, and better immunity along with other aspects of better general health.

Low heart rate variability correlates with migraine disease, increased inflammation, chronic pain syndromes, autoimmune diseases, anxiety/depression, and many other aspects of chronic illness. 

In chronic pain syndromes, the fight or flight reflex is never adequately toned down. You can imagine how exhausting being in a constant state of emergency could be.

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How can we best keep track of our HRV? What should we be looking for?

HRV may be calculated from a chest strap or other appliance recording your EKG. In a more convenient way, HRV also may be determined from your pulse. Using the pulse rather than the EKG allows devices such as finger clips, wristwatches, ear clips, etc. to serve as HRV monitors.

Probably the easiest way to follow HRV is by using your smartphone camera to read your pulse and using an associated app such as Easeday to calculate and record your HRV score.  At any given time you can see how your HRV is responding to relaxation training sessions, moods, and life’s events.  

Ideally, a pain app also includes a breathing pacer and information regarding HRV, including its use in treating chronic pain conditions. The Easeday app provides these, along with a headache diary, and relaxation training techniques.

Any improvement in HRV, either in real-time during a relaxation training session or long-term over months is good. Long-term decreases in HRV, on the other hand, may indicate illness, increased inflammation, mood changes, etc.

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Are doctors at all concerned with a person’s HRV?

They’re becoming concerned, but there’s always a lot of inertia in medicine as busy providers just try to get through their day. 

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Should they be more concerned?

The importance of monitoring heart rate variability in sickness and in health first came to the attention of psychologists in the 1980’s.  Physicians became more aware when the well-respected Framingham heart study showed that HRV correlated with both cardiovascular health and longevity.

If the burgeoning scientific literature on HRV is any indication, doctors in academic centers are now aggressively exploring the possibilities of adding HRV biofeedback to the treatment of many chronic diseases.

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What does HRV show them beyond the usual health data points such as blood pressure, weight, blood work, etc.?

Doctors are progressively acknowledging the prominent role of inflammation in chronic disease. The well-documented correlation of high HRV with low inflammation has raised the prospect of treating not just cardiovascular disease, but such illnesses as fibromyalgia, chronic pain syndrome, diabetes, autoimmune disease, and chronic fatigue syndrome with anything that increases HRV.

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What’s holding up progress with getting HRV in broader usage?

Several factors are probably at work involving both healthcare providers and their patients.

Old practice habits do change in healthcare, but sometimes very slowly. Progress in the fee-for-service model has been greatly impeded by the incentivization for treating illness instead of promoting wellness.

Again, the fact that the concept of HRV is somewhat harder to understand than many other measures has probably slowed its adoption even amongst health care providers. 

For those experiencing chronic pain, the need to accept a degree of self-responsibility for the prevention and treatment of chronic illness isn’t always as well received as prospects of a pharmaceutical cure. 

Realistically, if there were quick fixes for chronic disease conditions, there wouldn’t be any chronic disease conditions.

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Are there ways to improve HRV?

Yes. Your HRV baseline can be increased through biofeedback, meditation, exercise, lifestyle modifications, cognitive behavioral therapy, and other therapies.

It’s been said that you can’t improve what you can’t measure. In the scientific literature, HRV has come to be the gold standard to measure the balance in your autonomic nervous system.  

In simpler terms, your HRV is an indicator of your ability to go from a fight or flight mode to a rest and digest mode. Increasing that ability is well worth anybody’s effort, but in particular, it’s a key step in escaping the chronic pain trap.” Dr. Pete Lillydahl

In simpler terms, your HRV is an indicator of your ability to go from a fight or flight mode to a rest and digest mode. Increasing that ability is well worth anybody’s effort, but in particular, it’s a key step in escaping the chronic pain trap.

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I’ve read that there are general ranges that one should expect to be in if healthy, but that it’s very individual.

 HRV scores vary so much with age, overall health, medications, time of day, meals, coffee, alcohol, body position, mood, etc. that comparing yourself with other people (especially those younger than yourself) is not a good idea. 

What is important is the change you can make in your own HRV score.  You may see the change in real-time during a relaxation session, such as slow-paced belly breathing, but also with some effort, you can observe long-term trends in your baseline HRV over weeks, months or years.  

To see long-term trends in your HRV, you should try to take a daily 5-minute baseline HRV reading before doing any relaxation exercises. Ideally, this baseline recording would be taken at the same time each morning, under the same circumstances in relation to meals, medications, body position, coffee, activities, etc.

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Does it matter what you think about during HRV biofeedback relaxation training?

Anyway you chose to occupy your mind during an HRV session is OK, except that negative thoughts are taboo – They should be dismissed unemotionally as you return your attention to your present surroundings.  As you know, that’s called mindfulness. 

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Any more thoughts you would like to share about HRV or treating chronic pain?

Actually, lots of them for those having the time or inclination to take a deeper dive. For those who have read this far, thank you for your attention and best wishes on the road to recovery from any chronic health conditions you’re experiencing.

Red Background with white EKG lines going through the center.  A photo of Dr. Pete Lillydahl is placed center; he's smiling wearing a white shirt and blue sweater vest and stethoscope

For those interested in a deeper dive into HRV, how do you want to start?

Let’s begin a deeper dive with a disclaimer:

A few hundred thousand patient encounters in my private medical practice doesn’t make an academic study. Hopefully, though, clinical experience along with help from the academic literature can inform some carefully drawn conclusions about the relationship between chronic pain, the autonomic nervous system, and heart rate variability. None of the following is intended to be controversial.

The fight or flight reflex in overdrive:

Practicing as an ear, nose, and throat doctor in an over-achieving community of professors, scientists, high techies, extreme athletes, etc., I saw a disproportionate number of patients whom you might judge as being wound up too tight, too much of the time. 

 To be more scientific, let’s call the stereotypical Boulderite “sympathetic dominant” in recognition of the fact that in the type A individual, the sympathetic (fight or flight) half of the autonomic nervous system tends to be dominant over the parasympathetic (rest and digest) half.

HRV – a measure of autonomic nervous system balance:

Roughly speaking, think of the sympathetic (“fight or flight”) half of your autonomic nervous system (ANS) as being an accelerator and the parasympathetic (“rest and digest”) half of the ANS as being the brakes. A good balance between the two translates into a healthy response to life’s inevitable stressful events. 

The balance in the autonomic nervous system between the sympathetic accelerator and the parasympathetic brakes shows up in many ways in terms of bodily function. One normal physiologic event is that your heart beats faster during inhalation (a sympathetic event) and more slowly during exhalation (a parasympathetic event). That difference in heart rate during a respiratory cycle is referred to as heart rate variability, or simply HRV. Your HRV score is a measure of your brain applying the parasympathetic brake on your heart rate by way of the vagus nerve.  The vagus nerve, however, also innervates essentially all your other internal organs as well. Your heart rate variability, therefore, may be thought of as a general indicator of the balance in the autonomic nervous system as it regulates your bodily functions.  

Autonomic Nervous System (ANS) Balance in Health and Illness:

In a normal, healthy individual, the parasympathetic (rest and digest) half of the ANS is dominant over the sympathetic (fight or flight) half, except when special effort is required.   A higher HRV indicates a state of mental and physical rest and recovery. A lower HRV indicates a system in overdrive. A low HRV score is totally appropriate during acute challenges and emergencies. Under such circumstances, you both hit the accelerator and take your foot off the brake. 

Again, in the long run, higher baseline heart rate variability is associated with better cardiovascular health, longer life span, lower inflammation, and better health in general. Lower baseline HRV correlates with chronic pain, headache disorders, inflammation, anxiety, and depression.

A red background with a heart frame centered, featuring neurons of the autonomic nervous system (ANS).

ANS balance in Fibromyalgia and Chronic Pain  

People with fibromyalgia, as well as those experiencing the chronic pain syndromes that so often accompany it, tend to have relatively low HRV scores.  In the long run, their sympathetic nervous system isn’t adequately braked down. Feeling fatigued may result from always be in a fight or flight mode.

Being in a perpetual state of vigilance is primarily due to the weakness of the parasympathetic brake rather than to the strength of the sympathetic accelerator. In fact, over time, the sympathetic nervous system tone may also be reduced in chronic pain states such as fibromyalgia. It may be a hypersensitivity to what stress hormones are produced that keeps the system in a state of sympathetic dominance.

The good news is that parasympathetic tone can be increased by behavioral techniques such as an appropriate exercise program, a healthy sleep regimen, and relaxation training among other therapeutic modalities. 

The ability of the nervous system to return to normal function is referred to as “neuroplasticity” and may be observed on fMRI scans of the brain. 

HRV Biofeedback – Monitoring Your Stress Response

Seeing is believing. It’s motivating to be able to monitor progress objectively as well as symptomatically. Rising HRV scores are a measure of increasing the ability to put the brakes on the fight or flight reflex. 

Red background with heart frame featuring a biofeedback wrist band and smartphone.

Biofeedback I –  A Personal Journey

Over the course of a 36-year career, it would have been hard not to have noticed the relationship of such conditions as  TMJ/MPD syndrome, non-sinus related facial pain, bothersome tinnitus, most dizziness, most vocal disorders, chronic rhinosinusitis, and asthma (to name a few) to autonomic imbalance.

The body in general and the nervous system in particular just needs a rest now and then to stay healthy.  This basic principle of wellness came home first hand when I developed back spasms every late evening, negotiating our clinic’s new electronic medical record system.  To relieve these painful spasms, I rubbed my back against the doorknob to my office until the pain was relieved enough to return to work.

Biofeedback II – EMG Biofeedback for Muscle Tightness

Eventually, I tried what had worked well for my TMJ patients who were willing to make the effort – biofeedback.  On the internet, I bought a $150 muscle tension detecting device called Antense 2.   It was an electronic headset-like apparatus that informed me with an alarm when my forehead was too tight and needed to take some deep breaths and relax.  This technique is called EMG biofeedback-assisted relaxation training.  It worked great for my back.

The Halo Device and the Birth of Easeday Migraine

Upon retiring, we (BioTrak was co-founded by myself, my son and three other engineers) formed a company to make an electronically updated EMG headband called Halo to diagnose and treat bruxism (tooth clenching) in specific, and muscle tension in general. The Halo prototype worked great, but by then the investment community had moved on from devices to apps. No investment – no product on the shelf.

Meanwhile the field of pain and chronic disease had advanced:

  1. The prominent role of inflammation in most chronic diseases was identified and acknowledged.
  2. The regulatory function of the autonomic nervous system over inflammation was discovered.
  3. HRV had become accepted in the scientific literature as the gold standard for measuring autonomic function.
  4. Technology had advanced so that the user’s pulse could be detected with the light in a smartphone camera.  From that input heart rate variability could be calculated by an algorithm built into a smart phone app. 

In a separate development,  Dr. Dawn Buse, a renowned behavioral therapist specializing in headaches and chronic pain believed in what we were doing and produced the relaxation training content for us.  For us, the headache was a user-acceptable entrance into the sensitive subject of mood and its role in sickness and health. 

Easeday Migraine with HRV biofeedback is the result of this journey.  Version 3  of Easeday was released in the Apple app store in January. An Android version is planned for this fall pending funding.

red background with heart frame in the center featuring hand/shoulder/hips/leg highlighted as if in pain

CHRONIC PAIN SYNDROME– What is it?

  • Acute (nociceptive) pain may persist for weeks, months or years, but chronic pain syndrome is not the same as long standing or recurrent acute pain. It involves mood issues that need to be dealt with as well as pain issues. Feelings of helplessness and hopelessness, sleep disturbances, and a reduced feeling of pleasure are very much part of chronic pain syndrome. 
  • Chronic pain makes the mood worse. Low mood makes pain tolerance worse. This is the vicious cycle of chronic pain syndrome.
  • It is possible but uncommon to find an anatomic or pharmaceutical cure for any acute pain component that in turn breaks the chronic pain cycle by itself.
  • There are both mood and anatomic factors playing a role in chronic pain syndrome that must both be addressed to restore the best quality of life possible under the circumstances. This whole-person approach acknowledges the biopsychosocial nature of chronic pain.
  • The best results for escaping the vicious cycle of chronic pain syndrome come from integrating some combination of an appropriate pharmaceutical regimen with behavioral therapy, lifestyle modifications (including exercise, sleep optimization, and positive social interactions), meditation, counselling, a therapy involving human touch, pets, music therapy, hobbies, and whatever else has some reasonable logic or evidence basis behind it.
  • The first step in escaping the chronic pain cycle is self- empowerment. Taking responsibility for as much of the treatment and prevention as possible should replace the dead end of feeling like a helpless victim waiting to be cured. Unfortunately, that wait could be long.
  • Chronic pain syndromes such as migraine disease, chronic daily headaches, TMJ/MPD syndrome, fibromyalgia, chronic neck, back, shoulder, and pelvic pain are called co-morbid, meaning they tend occur together and must have some reason for doing so.
  • Tinnitus, irritable bowel syndrome, asthma, chronic rhinosinusitis, psoriasis, anxiety, insomnia, chronic fatigue, depression, panic disorder, and many other conditions are often included as chronic pain syndromes because of their tendency to be co-morbid with the syndromes involving mostly  pain. Many of these conditions are exacerbated by stressful events, raising the possibility that resilience to stress is a key feature in their causes and solutions.
  • Chronic pain syndromes have other things in common:
    • Central sensitization: the inability of the brain to appropriately screen out sensory input such as milder pains, sounds, bright light, itching, odors, etc.
    • A low grade inflammation readily detectable with blood studies.
    • A persistence of the fight or flight reflex after a threat has passed.
    • Low heart rate variability (a measure of the body’s ability to put the brakes on the fight or flight reflex)
    • Characteristic abnormal (but reversible) findings on fMRI scans of the brain.

OPIOIDS – Personal Opinion

In the short run, opioids may be very effective at both relieving acute (nociceptive) pain and elevating mood. They often do this at an unacceptable price, however. Among other drawbacks, in the long run, opioids prolong and intensify the pain by suppressing the effect of endorphins -the body’s own system of naturally occurring, non-addictive analgesic chemicals. Endorphins compete for the same tissue binding sites as opioids. While people who have become dependent on opioids may need to judiciously continue them to function, the wisdom of starting chronic pain patients on opioids must be questioned. Any therapeutic modality that reduces the need for opioids should be considered in the treatment plan for chronic pain conditions.

Further reading:

Have you ever checked your HRV pattern? What do you think of its potential in monitoring our health and focus on improving it?


Thank you for visiting my blog today. I am committing to posting once a week by Friday.  However, as you know, my new normal means that sometimes I have to listen to my body, and I cannot follow through as planned. Thank you for your understanding.


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12 thoughts on “HRV and Fibromyalgia: What’s Your Heart Rate Variability?

  • July 19, 2021 at 1:52 pm
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    Very interesting! I know my HRV is all over the place as I have dysautonomia, so I’ve been trying to be a bit more restful to calm it down. Although that tends to come hard to me I admit!

    Reply
    • July 19, 2021 at 5:44 pm
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      I hadn’t thought about how things like dysautonomia would affect HRV. Had you already been monitoring it?

      Reply
  • July 19, 2021 at 4:06 pm
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    This is a great post full of information! I had not heard of HRV, and you made a complex subject accessible. I’m definitely looking into the app mentioned, and I’m going to talk to my rehab doctor about HRV and biofeedback. It is encouraging to learn about it, because this is something we as patients can use to help improve our day-to-day lives. Thanks so much for all this info!

    Reply
    • July 19, 2021 at 5:42 pm
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      Thank you, Melissa for your comment. It means a lot to know that you have found this to be helpful information. I’m constantly looking to make sense of my illness and best ways to manage it. Focusing on calming down my ANS makes a lot of sense to me. I wish you all the best in your wellness journey.

      Reply
  • July 20, 2021 at 12:23 am
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    This was such an interesting read. Mine is all over the place!

    I went through the FitBit stage of illness in 2017 and quickly decided that it was stressing me out way too much. I was overly focused on what was happening with sleep, etc. However, I love it for day time use. I’m so glad you met Dr. Lillydahl. This was an interesting read for me because I went through this testing in 2015 and naturally, they didn’t explain any of it! That’s Taiwan for you. Thanks for a great post, Katie.

    Reply
    • July 21, 2021 at 8:53 am
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      Glad our discussion helped to clarify what HRV is. I understand what you mean by getting obsessed/anxious about sleep monitoring. I’ve stopped for the moment. Funny how there are stages of going through chronic illness, isn’t there?

      Reply
    • July 27, 2021 at 4:10 pm
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      Heart rate variability is such an important measure. It’s something I’ve been working really hard to improve recently via yoga and breathing exercises. As people with chronic illness have an overactive sympathetic nervous system I feel heart rate variability should be one of the most important tests done and measured. Working on improving it and activating my parasympathetic nervous system has made such a huge difference for me. Thank you for sharing all of this information 🙂

      Reply
      • July 27, 2021 at 7:44 pm
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        Good to hear someone else is working towards this. Are you finding improvement?

  • July 27, 2021 at 11:29 pm
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    What a detailed and interesting interview. I love that you’re providing such helpful articles on your blog, and also opinions from actual medical professionals!

    Reply
    • July 28, 2021 at 8:42 am
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      Yes, I sure loved the back and forth discussion with Dr. Pete. I love that he understands the need for body/mind treatment. I’m interested in checking out his migraine app, but I don’t have an iPhone. Hopefully, it comes out on Android this fall.

      Reply
  • August 1, 2021 at 2:30 am
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    This is such an interesting article and a huge thank you to Dr. Pete Lillydahl for taking the time to share his knowledge, and to you, Katie, for taking the time to put it all together! I learned a lot and it has piqued my interest in exploring it further!

    Reply
    • August 6, 2021 at 8:55 am
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      Yes, Dr. Pete shared so much. I learned a lot from him. Since this post, I’ve been working on HRV (calming nervous system) techniques he mentioned plus a few others. I have had a consistent raise in HRV from 16ish (several months) to 26 (for the last two weeks). This has also been two weeks that I’ve been more energetic, more alert and feeling healthy. I’ve been sleeping decently, too!

      Reply

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