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Otolaryngologist Brian F. Worden discusses his article, “The surprising link between migraine and tinnitus.” He reveals that for the 26-47 percent of tinnitus patients who also report migraines, the tinnitus may actually be an atypical migraine symptom, even without a headache. Brian explains how migraine, a complex neurological disorder, activates the trigeminal nerve, which can affect the inner ear and amplify sensory hypersensitivity, putting existing auditory hyperactivity into “overdrive.” He outlines how to identify fluctuating, migraine-related tinnitus (which worsens with stress or sleep disruption) versus constant tinnitus. The discussion covers practical migraine-specific therapies that can reduce tinnitus severity, including trigger avoidance, nutritional supplements, and medications. Learn how treating the underlying neurological disorder, not just the ear, may be the key to managing tinnitus.

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Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Brian F. Worden. He is an otolaryngologist. Today’s KevinMD article is “The surprising link between migraine and tinnitus.” Brian, welcome to the show.

Brian F. Worden: Hey, thanks for having me. It is a pleasure to be here.

Kevin Pho: All right. Before talking about your article, just briefly share your story and journey.

Brian F. Worden: OK. Well, I grew up mostly in California. I went to college in California. I went to medical school at the University of California, San Francisco, and I did my residency training in otolaryngology at Stanford. I have been a practicing otolaryngologist based in Southern California since about 2009. In recent years, I have been particularly focused on improving the care for people with intrusive tinnitus.

Kevin Pho: All right. Tell us about the article for those who didn’t get a chance to read it: “The surprising link between migraine and tinnitus.”

Brian F. Worden: Yes. I will give you a little bit of background first. One of the things that really stood out to me relatively early on in my clinical practice was the lack of available resources and treatment options for people that have intrusive tinnitus. That word “tinnitus,” for those of you who aren’t familiar with it, refers to a perception of sound. There is not actually a sound in the environment. A lot of people call it ringing in the ears, but the sound could be a buzz. It could be a hiss. It could be any number of sounds actually. Tinnitus is usually associated with hearing loss, and it is quite common. It probably affects close to 20 percent of the population.

Fortunately for the majority of people that have tinnitus, it is an annoyance. It is bothersome, but it is not a huge issue. But there is a subset of people that have tinnitus, maybe 5 percent to 10 percent of people that have tinnitus, who find it so intrusive and so disruptive that it ruins their quality of life. The general consensus for many years among the medical community was that there just weren’t good treatment options for people with tinnitus. I know that personally, I did not receive a lot of education about tinnitus in medical school, or even in residency we didn’t talk that much about tinnitus.

So when I found myself in independent clinical practice and I was meeting these people in my clinic that were telling me about how their tinnitus was ruining their life, I was really woefully underprepared to help these people. But I could see how much the tinnitus was really causing suffering, and so I spent a lot of time digging deeper into the topic, looking into the clinical research and talking to experts to see what kinds of things really were out there to help people with tinnitus.

What I discovered was that there actually is a literature on this. There are a number of strategies that have been shown in clinical research to reduce the severity of tinnitus and reduce the burden of tinnitus, even a number of randomized controlled trials. The techniques that tend to work include things like specialized forms of cognitive behavioral therapy that are tailored for tinnitus, mindfulness techniques, certain forms of sound therapy, something called tinnitus retraining therapy, and a few other strategies.

After I discovered that there were these treatments that were available for people with tinnitus, I was feeling a lot more optimistic. I started looking around my area in Southern California for places that I could send my patients that had tinnitus to help them out. What I discovered was that there are literally only a handful of places in the whole country that offer evidence-based treatment for patients that have tinnitus. It is probably because of insurance reimbursement. It is often not covered by insurance. It is not well reimbursed by insurance companies. So there are not a lot of places that offer that kind of treatment.

So that motivated me to create a multifaceted, evidence-based treatment program for patients with tinnitus at my own medical center in Southern California. After doing that for a while, we saw some really encouraging results where a lot of patients were really finding benefit from the techniques that we were employing. From there we developed a website and an app-based program to expose even more people to the opportunity for these kinds of evidence-based treatments.

One thing that became clear to me after treating a lot of patients with tinnitus was that there was a subtype of tinnitus sufferer that had symptoms that were a little bit different. The typical patient with tinnitus tends to be somebody that has hearing loss, maybe somebody that’s a little bit older, that has had some loud noise exposure in their life. Their tinnitus is rather constant. It is a tone or a buzz that is there all the time. Maybe it is a little bit louder when they are in a really quiet environment, but otherwise, it is pretty stable.

But again, there is this subtype of patients that have tinnitus that are a little bit different. They describe intermittent tinnitus or tinnitus that fluctuates pretty significantly in either character or volume over the course of a typical week. Oftentimes they describe that their tinnitus may get worse if they are stressed, if they are not well-rested, if they are hungry, or other factors like that, maybe even dietary factors.

So I found this rather curious. Again, I found myself looking into the clinical literature to see if there were other people out there that have described this phenomenon. Sure enough, I came across some other specialists, Dr. Michael Teixido and Dr. Hamid Djalilian, who had described a variant of atypical migraine in which patients were actually predominantly reporting ear-related symptoms. It has been called cochlear migraine or otologic migraine. One of the symptoms that these patients oftentimes report is fluctuating tinnitus.

That made a lot of sense to me because I was already in my practice seeing a lot of patients that have atypical migraine because they were coming in to see me with things like unexplained ear pain, unexplained ear pressure or ear fullness, episodic vertigo, or even sinus-type headaches despite having no objective inflammation in their sinuses.

So what I started doing, and several other specialists across the country started doing, is treating these patients that have fluctuating tinnitus (this subset of patients with tinnitus) with migraine-specific therapies. We started seeing that these patients, many of them were actually seeing improvements in their tinnitus. So the purpose of the article that I published at KevinMD was to spread the word about this, to let clinicians know that this is something that should be on their radar, and to let even patients know if they are somebody that has fluctuating tinnitus that this is something that offers a parallel treatment pathway, something else that might actually help out with their symptoms.

Kevin Pho: How about in a primary care setting? So tinnitus is a relatively common complaint that people come in with in my own clinic. What are some clues to the story I should look out for to see whether tinnitus is part of that variant that you just described?

Brian F. Worden: That is a great question. First of all, I think for people in primary care, asking a couple of questions to their patients with tinnitus first, just as a screening, can help differentiate somebody that has just typical tinnitus that is no big deal from somebody that has tinnitus that is really affecting their quality of life. Just asking them how much it bothers them. Is it something that interferes with that normal functioning? Is it something that is making them feel anxious or depressed? For people that just say: “Oh no, it is just kind of annoying. But most of the time I can forget about it,” those kinds of patients probably don’t need any sort of evaluation other than maybe a hearing test. But for people that have tinnitus that is really intrusive, really bothersome, and eroding their quality of life, those people should be seen by an otolaryngologist and have a full evaluation to see if there is any sort of readily reversible cause of tinnitus and perhaps plug them into different treatment options.

With regard to migraine-associated tinnitus, there are a few clues that somebody with tinnitus may display that gives you an idea that migraine may be contributing to their tinnitus, and that perhaps migraine-specific therapies would help. One of them, as I mentioned earlier, is fluctuating tinnitus. If somebody says that their tinnitus is coming and going on a daily basis, or that some days it sounds like a tone and some days it sounds like a jackhammer, or some days it is soft and some days it is loud, that is a clue. If somebody has other symptoms other than just tinnitus, other ear-related symptoms like intermittent ear pain or intermittent ear fullness, episodes of spinning vertigo or other kinds of dizziness, or if there is a family history of migraine or other symptoms like that, those can all be clues that somebody may have migraine contributing to their tinnitus pathophysiology.

Kevin Pho: When we send a patient with tinnitus to an otolaryngologist like yourself, just tell us what you do with them in the office in terms of tests you may or may not order. Just take us through the diagnostic process once we refer these patients to you.

Brian F. Worden: I think when we see somebody with tinnitus in the clinic, the first thing that we are doing is taking a very thorough history. So we want to know about their tinnitus. We have them describe their tinnitus, when they are experiencing their tinnitus, and how much their tinnitus is affecting their quality of life. Then we are asking about other symptoms that they have, you know, other ear-related symptoms. Are they having headaches? Are they having dizziness and vertigo? Are they having things like that? Do they have a history of loud noise exposure, other sorts of ear pathologies, and so on and so forth.

After we get a good history, then we are going to do a good physical examination of their ears because we want to see: Is there something going on here that may be contributing to their tinnitus that we can actually fix, something that is readily reversible? Do they have a cerumen impaction that is touching their eardrum? We just remove that cerumen impaction and that makes their tinnitus go away? Honestly, I have had patients like that and they are very satisfied because you actually fix their tinnitus in one visit.

Do they have temporomandibular disorder? Because temporomandibular disorder is definitely something that can contribute to tinnitus, and for many patients, just properly treating the temporomandibular disorder can improve their tinnitus. Do they have a migraine disorder as we are talking about today? If so, doing things in the realm of treating their migraine disorder has potential to improve their tinnitus.

Or is there some other medical condition that we should be aware of that needs to be managed? Do they have chronic otitis media that we need to treat medically or surgically? Do they have Eustachian tube dysfunction? Do they have chronic sinusitis or something like that also that we can manage that has some potential in improving their tinnitus?

On top of that, they are going to have a thorough hearing test with an audiologist because, as I said, the majority of people that have tinnitus have some degree of hearing loss. For many people, if we fit them with well-programmed digital hearing aids, just that can make a big difference with regard to their tinnitus because we are amplifying a lot of those frequencies that their ears are missing. By amplifying those frequencies, oftentimes it kind of masks the tinnitus and makes it less noticeable and bothersome for those patients.

Kevin Pho: When it comes to these fluctuating migraine-related tinnitus, is that diagnosis made purely based on the history? Are there any specific diagnostic tests that can objectify that finding?

Brian F. Worden: No, not really. Unfortunately, there is not a blood test or an imaging test that is going to show us conclusively whether somebody has migraine-associated tinnitus. So it is a diagnosis of exclusion or ruling out any other causes that could produce those kinds of symptoms. As I said, there are some clues just based on their history.

Just like any other migraine disorder or migraine variant, oftentimes it is a process of trial and error where we think: “Well, maybe this is migraines. Let’s try out some migraine therapy and see if it helps.” There are a variety of things that we can do in that realm ranging from lifestyle modifications, migraine trigger avoidance strategies to nutritional supplements, even to migraine prophylactic medications.

Kevin Pho: So talk about some of those management approaches. When you talk about lifestyle, in your article you talk about even something as simple as diet, right? That can make a difference.

Brian F. Worden: Yeah. I mean that is the thing about migraine: We think that migraine in most people is a genetic predisposition. So it tends to run in families. It probably, for most people, is related to ion channel variants that they have inherited. They have because of that a lifelong predisposition to migraine. Whether or not they have migraine symptoms is going to depend on what physiologic state their body is in and what kinds of exposures their body is exposed to. There are a number of well-documented triggers that we know tend to provoke migraine activity. The thought is that they cause some increased neuronal activity that can, under certain circumstances, push somebody over this threshold that then triggers migraine activity.

There are a number of different kinds of treatments. We know as far as physiologic states, when people are tired, if they are sleep-deprived, they are much more likely to have migraine symptoms. Stress is probably the number one trigger for migraine symptoms. Hormonal fluctuations—things like the menstrual period, pregnancy, or menopause—can be a big factor. Hunger and dehydration are big factors for migraine as well. There are certain foods that can be triggers for migraines for a number of people. Probably the most common ones would be things like chocolate, red wine, caffeine, aged cheeses, processed meats, and things like that. For a number of people, if they can eliminate those kinds of foods or at least minimize those kinds of foods from their diet, that can have a hugely beneficial effect on their migraine symptoms.

Then for some people, it is a sensory overload. So some people can have migraine triggered by looking at the sun, really loud sounds, or really strong odors. There are even people that tend to be sensitive to changes in barometric pressure. So they will have migraine with weather changes or they will have migraine symptoms when they fly on an airplane. Those are some of the kind of classic lifestyle, environmental factors that can influence migraine.

When we are approaching somebody that we think has migraine influencing either tinnitus or other symptoms, we are going to educate them about these kinds of dietary and environmental triggers and encourage them as much as they can to try and minimize their exposure to them. Obviously, some of those things are easier to avoid than others. But even just focusing on getting good quality sleep, treating unrecognized sleep apnea, trying to manage stress in healthy ways, and minimizing exposure to some of these foods can be hugely beneficial.

Another really low-risk thing that we recommend to a lot of our migraine patients are some dietary supplements. So things like magnesium, vitamin B2, coenzyme Q10, and even melatonin can be helpful for patients with migraine.

If those low-risk strategies are not effective enough at reducing symptoms, then there are medications. Migraine medications tend to fall into two major classes. There are the abortive medicines. The abortive medicines really are more for the headache-type symptoms of migraine. So you start feeling a headache and you take your triptan, and that can shorten the duration of the headache, maybe make the headache less severe. Those are less applicable to these kinds of otologic symptoms that we are talking about.

Generally, if we are going to use medications for somebody that has ear symptoms related to migraine, we are talking about taking a prophylactic medicine. That means taking a medicine every day to try and prevent those migraine symptoms. The thought is that the medication is raising that neuronal threshold so that it is harder to reach that threshold that triggers migraine activity. There are a number of different medication classes that can be helpful for migraine prophylaxis, ranging from calcium channel blockers to beta blockers, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, and anti-epileptics like topiramate. Now there are even the newer, more expensive CGRP inhibitor-type medications.

Kevin Pho: We are talking to Brian Worden. He is an otolaryngologist. Today’s KevinMD article is “The surprising link between migraine and tinnitus.” Brian, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Brian F. Worden: Sure. So, for the clinicians out there, my message is: Please don’t underestimate the negative effects that intrusive tinnitus can have on our patients. Know that effective tinnitus treatment does exist and that it is becoming more accessible as treatments are being migrated into the virtual space. If you don’t have a center in your geographic area that is offering quality evidence-based tinnitus treatment, please consider directing your patients to AlleviateTinnitus.com, where they can access a free, thorough instructional workshop on the subject that I have put together, and that can get them plugged into some helpful evidence-based treatment strategies.

Kevin Pho: Brian, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Brian F. Worden: Thanks for having me. It has been great.