Why your migraine could be inflicting your tinnitus [PODCAST]

Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on outdated episodes!

Otolaryngologist Brian F. Worden discusses his article, “The shocking hyperlink between migraine and tinnitus.” He reveals that for the 26-47 % of tinnitus sufferers who additionally report migraines, the tinnitus may very well be an atypical migraine symptom, even with out a headache. Brian explains how migraine, a posh neurological dysfunction, prompts the trigeminal nerve, which may have an effect on the interior ear and amplify sensory hypersensitivity, placing current auditory hyperactivity into “overdrive.” He outlines learn how to determine fluctuating, migraine-related tinnitus (which worsens with stress or sleep disruption) versus fixed tinnitus. The dialogue covers sensible migraine-specific therapies that may cut back tinnitus severity, together with set off avoidance, dietary dietary supplements, and drugs. Find out how treating the underlying neurological dysfunction, not simply the ear, would be the key to managing tinnitus.

Our presenting sponsor is Microsoft Dragon Copilot.

Microsoft Dragon Copilot, your AI assistant for scientific workflow, is reworking how clinicians work. Now you may streamline and customise documentation, floor info proper on the level of care, and automate duties with only a click on.

A part of Microsoft Cloud for Healthcare, Dragon Copilot affords an extensible AI workspace and a single, built-in platform to assist unlock new ranges of effectivity. Plus, it’s backed by a confirmed observe report and a long time of scientific experience, and it’s constructed on a basis of belief.

It’s time to ease your administrative burdens and keep targeted on what issues most with Dragon Copilot, your AI assistant for scientific workflow.

VISIT SPONSOR → https://aka.ms/kevinmd

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://www.kevinmd.com/beneficial

Transcript

Kevin Pho: Hello. Welcome to the present. Subscribe at KevinMD.com/podcast. In the present day, we welcome Brian F. Worden. He’s an otolaryngologist. In the present day’s KevinMD article is “The shocking hyperlink between migraine and tinnitus.” Brian, welcome to the present.

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

Kevin Pho: All proper. Earlier than speaking about your article, simply briefly share your story and journey.

Brian F. Worden: OK. Nicely, I grew up largely in California. I went to school in California. I went to medical college on the College of California, San Francisco, and I did my residency coaching in otolaryngology at Stanford. I’ve been a working towards otolaryngologist based mostly in Southern California since about 2009. Lately, I’ve been notably targeted on bettering the look after folks with intrusive tinnitus.

Kevin Pho: All proper. Inform us concerning the article for many who didn’t get an opportunity to learn it: “The shocking hyperlink between migraine and tinnitus.”

Brian F. Worden: Sure. I offers you just a little little bit of background first. One of many issues that actually stood out to me comparatively early on in my scientific observe was the shortage of obtainable assets and therapy choices for those who have intrusive tinnitus. That phrase “tinnitus,” for these of you who aren’t aware of it, refers to a notion of sound. There’s not really a sound within the setting. Lots of people name it ringing within the ears, however the sound could possibly be a buzz. It could possibly be a hiss. It could possibly be any variety of sounds really. Tinnitus is normally related to listening to loss, and it’s fairly frequent. It most likely impacts shut to twenty % of the inhabitants.

Happily for almost all of those who have tinnitus, it’s an annoyance. It’s bothersome, however it’s not an enormous situation. However there’s a subset of those who have tinnitus, perhaps 5 % to 10 % of those who have tinnitus, who discover it so intrusive and so disruptive that it ruins their high quality of life. The final consensus for a few years among the many medical neighborhood was that there simply weren’t good therapy choices for folks with tinnitus. I do know that personally, I didn’t obtain loads of schooling about tinnitus in medical college, and even in residency we didn’t discuss that a lot about tinnitus.

So when I discovered myself in unbiased scientific observe and I used to be assembly these folks in my clinic that had been telling me about how their tinnitus was ruining their life, I used to be actually woefully underprepared to assist these folks. However I might see how a lot the tinnitus was actually inflicting struggling, and so I spent loads of time digging deeper into the subject, trying into the scientific analysis and speaking to consultants to see what sorts of issues actually had been on the market to assist folks with tinnitus.

What I found was that there really is a literature on this. There are a variety of methods which have been proven in scientific analysis to cut back the severity of tinnitus and cut back the burden of tinnitus, even numerous randomized managed trials. The strategies that are likely to work embrace issues like specialised types of cognitive behavioral remedy which can be tailor-made for tinnitus, mindfulness strategies, sure types of sound remedy, one thing known as tinnitus retraining remedy, and some different methods.

After I found that there have been these therapies that had been out there for folks with tinnitus, I used to be feeling much more optimistic. I began trying round my space in Southern California for locations that I might ship my sufferers that had tinnitus to assist them out. What I found was that there are actually solely a handful of locations in the entire nation that provide evidence-based therapy for sufferers which have tinnitus. It’s most likely due to insurance coverage reimbursement. It’s typically not coated by insurance coverage. It isn’t properly reimbursed by insurance coverage firms. So there will not be loads of locations that provide that form of therapy.

In order that motivated me to create a multifaceted, evidence-based therapy program for sufferers with tinnitus at my very own medical middle in Southern California. After doing that for some time, we noticed some actually encouraging outcomes the place loads of sufferers had been actually discovering profit from the strategies that we had been using. From there we developed a web site and an app-based program to reveal much more folks to the chance for these sorts of evidence-based therapies.

One factor that turned clear to me after treating loads of sufferers with tinnitus was that there was a subtype of tinnitus sufferer that had signs that had been just a little bit completely different. The standard affected person with tinnitus tends to be anyone that has listening to loss, perhaps anyone that’s just a little bit older, that has had some loud noise publicity of their life. Their tinnitus is slightly fixed. It’s a tone or a buzz that’s there on a regular basis. Perhaps it’s a little bit louder when they’re in a extremely quiet setting, however in any other case, it’s fairly secure.

However once more, there may be this subtype of sufferers which have tinnitus which can be just a little bit completely different. They describe intermittent tinnitus or tinnitus that fluctuates fairly considerably in both character or quantity over the course of a typical week. Oftentimes they describe that their tinnitus could worsen if they’re careworn, if they don’t seem to be well-rested, if they’re hungry, or different elements like that, perhaps even dietary elements.

So I discovered this slightly curious. Once more, I discovered myself trying into the scientific literature to see if there have been different folks on the market which have described this phenomenon. Positive sufficient, I got here throughout another specialists, Dr. Michael Teixido and Dr. Hamid Djalilian, who had described a variant of atypical migraine during which sufferers had been really predominantly reporting ear-related signs. It has been known as cochlear migraine or otologic migraine. One of many signs that these sufferers oftentimes report is fluctuating tinnitus.

That made loads of sense to me as a result of I used to be already in my observe seeing loads of sufferers which have atypical migraine as a result of they had been coming in to see me with issues like unexplained ear ache, unexplained ear strain or ear fullness, episodic vertigo, and even sinus-type complications regardless of having no goal irritation of their sinuses.

So what I began doing, and several other different specialists throughout the nation began doing, is treating these sufferers which have fluctuating tinnitus (this subset of sufferers with tinnitus) with migraine-specific therapies. We began seeing that these sufferers, a lot of them had been really seeing enhancements of their tinnitus. So the aim of the article that I revealed at KevinMD was to unfold the phrase about this, to let clinicians know that that is one thing that needs to be on their radar, and to let even sufferers know if they’re anyone that has fluctuating tinnitus that that is one thing that provides a parallel therapy pathway, one thing else which may really assist out with their signs.

Kevin Pho: How about in a major care setting? So tinnitus is a comparatively frequent grievance that folks are available in with in my very own clinic. What are some clues to the story I ought to look out for to see whether or not tinnitus is a part of that variant that you just simply described?

Brian F. Worden: That could be a nice query. Initially, I feel for folks in major care, asking a few inquiries to their sufferers with tinnitus first, simply as a screening, may help differentiate anyone that has simply typical tinnitus that’s no massive deal from anyone that has tinnitus that’s actually affecting their high quality of life. Simply asking them how a lot it bothers them. Is it one thing that interferes with that ordinary functioning? Is it one thing that’s making them really feel anxious or depressed? For those that simply say: “Oh no, it’s simply form of annoying. However more often than not I can overlook about it,” these sorts of sufferers most likely don’t want any kind of analysis aside from perhaps a listening to check. However for those who have tinnitus that’s actually intrusive, actually bothersome, and eroding their high quality of life, these folks needs to be seen by an otolaryngologist and have a full analysis to see if there may be any kind of readily reversible reason for tinnitus and maybe plug them into completely different therapy choices.

With regard to migraine-associated tinnitus, there are just a few clues that anyone with tinnitus could show that provides you an concept that migraine could also be contributing to their tinnitus, and that maybe migraine-specific therapies would assist. Considered one of them, as I discussed earlier, is fluctuating tinnitus. If anyone says that their tinnitus is coming and going each day, or that some days it feels like a tone and a few days it feels like a jackhammer, or some days it’s smooth and a few days it’s loud, that could be a clue. If anyone has different signs different than simply tinnitus, different ear-related signs like intermittent ear ache or intermittent ear fullness, episodes of spinning vertigo or different kinds of dizziness, or if there’s a household historical past of migraine or different signs like that, these can all be clues that anyone could have migraine contributing to their tinnitus pathophysiology.

Kevin Pho: After we ship a affected person with tinnitus to an otolaryngologist like your self, simply inform us what you do with them within the workplace by way of assessments you could or could not order. Simply take us by the diagnostic course of as soon as we refer these sufferers to you.

Brian F. Worden: I feel after we see anyone with tinnitus within the clinic, the very first thing that we’re doing is taking a really thorough historical past. So we wish to learn about their tinnitus. We’ve got them describe their tinnitus, when they’re experiencing their tinnitus, and the way a lot their tinnitus is affecting their high quality of life. Then we’re asking about different signs that they’ve, you understand, different ear-related signs. Are they having complications? Are they having dizziness and vertigo? Are they having issues like that? Have they got a historical past of loud noise publicity, different kinds of ear pathologies, and so forth and so forth.

After we get a superb historical past, then we’re going to do a superb bodily examination of their ears as a result of we wish to see: Is there one thing happening right here which may be contributing to their tinnitus that we will really repair, one thing that’s readily reversible? Have they got a cerumen impaction that’s touching their eardrum? We simply take away that cerumen impaction and that makes their tinnitus go away? Truthfully, I’ve had sufferers like that and they’re very happy since you really repair their tinnitus in a single go to.

Have they got temporomandibular dysfunction? As a result of temporomandibular dysfunction is certainly one thing that may contribute to tinnitus, and for a lot of sufferers, simply correctly treating the temporomandibular dysfunction can enhance their tinnitus. Have they got a migraine dysfunction as we’re speaking about at this time? If that’s the case, doing issues within the realm of treating their migraine dysfunction has potential to enhance their tinnitus.

Or is there another medical situation that we must always concentrate on that must be managed? Have they got continual otitis media that we have to deal with medically or surgically? Have they got Eustachian tube dysfunction? Have they got continual sinusitis or one thing like that additionally that we will handle that has some potential in bettering their tinnitus?

On high of that, they will have an intensive listening to check with an audiologist as a result of, as I stated, nearly all of those who have tinnitus have some extent of listening to loss. For many individuals, if we match them with well-programmed digital listening to aids, simply that may make a giant distinction with regard to their tinnitus as a result of we’re amplifying loads of these frequencies that their ears are lacking. By amplifying these frequencies, oftentimes it form of masks the tinnitus and makes it much less noticeable and bothersome for these sufferers.

Kevin Pho: In the case of these fluctuating migraine-related tinnitus, is that analysis made purely based mostly on the historical past? Are there any particular diagnostic assessments that may objectify that discovering?

Brian F. Worden: No, probably not. Sadly, there may be not a blood check or an imaging check that’s going to point out us conclusively whether or not anyone has migraine-associated tinnitus. So it’s a analysis of exclusion or ruling out another causes that might produce these sorts of signs. As I stated, there are some clues simply based mostly on their historical past.

Identical to another migraine dysfunction or migraine variant, oftentimes it’s a technique of trial and error the place we expect: “Nicely, perhaps that is migraines. Let’s check out some migraine remedy and see if it helps.” There are a selection of issues that we will do in that realm starting from life-style modifications, migraine set off avoidance methods to dietary dietary supplements, even to migraine prophylactic drugs.

Kevin Pho: So speak about a few of these administration approaches. Whenever you speak about life-style, in your article you speak about even one thing so simple as food plan, proper? That may make a distinction.

Brian F. Worden: Yeah. I imply that’s the factor about migraine: We predict that migraine in most individuals is a genetic predisposition. So it tends to run in households. It most likely, for most individuals, is expounded to ion channel variants that they’ve inherited. They’ve due to {that a} lifelong predisposition to migraine. Whether or not or not they’ve migraine signs goes to depend upon what physiologic state their physique is in and what sorts of exposures their physique is uncovered to. There are a variety of well-documented triggers that we all know have a tendency to impress migraine exercise. The thought is that they trigger some elevated neuronal exercise that may, below sure circumstances, push anyone over this threshold that then triggers migraine exercise.

There are a variety of various sorts of therapies. We all know so far as physiologic states, when individuals are drained, if they’re sleep-deprived, they’re much extra prone to have migraine signs. Stress might be the primary set off for migraine signs. Hormonal fluctuations—issues just like the menstrual interval, being pregnant, or menopause—could be a massive issue. Starvation and dehydration are massive elements for migraine as properly. There are specific meals that may be triggers for migraines for numerous folks. Most likely the most typical ones could be issues like chocolate, crimson wine, caffeine, aged cheeses, processed meats, and issues like that. For numerous folks, if they’ll get rid of these sorts of meals or at the least reduce these sorts of meals from their food plan, that may have a vastly useful impact on their migraine signs.

Then for some folks, it’s a sensory overload. So some folks can have migraine triggered by trying on the solar, actually loud sounds, or actually sturdy odors. There are even those who are typically delicate to adjustments in barometric strain. So they may have migraine with climate adjustments or they may have migraine signs after they fly on an airplane. These are a few of the form of traditional life-style, environmental elements that may affect migraine.

After we are approaching anyone that we expect has migraine influencing both tinnitus or different signs, we’re going to educate them about these sorts of dietary and environmental triggers and encourage them as a lot as they’ll to try to reduce their publicity to them. Clearly, a few of these issues are simpler to keep away from than others. However even simply specializing in getting good high quality sleep, treating unrecognized sleep apnea, making an attempt to handle stress in wholesome methods, and minimizing publicity to a few of these meals might be vastly useful.

One other actually low-risk factor that we advocate to loads of our migraine sufferers are some dietary dietary supplements. So issues like magnesium, vitamin B2, coenzyme Q10, and even melatonin might be useful for sufferers with migraine.

If these low-risk methods will not be efficient sufficient at lowering signs, then there are drugs. Migraine drugs are likely to fall into two main courses. There are the abortive medicines. The abortive medicines actually are extra for the headache-type signs of migraine. So that you begin feeling a headache and you are taking your triptan, and that may shorten the length of the headache, perhaps make the headache much less extreme. These are much less relevant to those sorts of otologic signs that we’re speaking about.

Typically, if we’re going to use drugs for anyone that has ear signs associated to migraine, we’re speaking about taking a prophylactic medication. Which means taking a medication each day to try to stop these migraine signs. The thought is that the treatment is elevating that neuronal threshold in order that it’s tougher to achieve that threshold that triggers migraine exercise. There are a variety of various treatment courses that may be useful for migraine prophylaxis, starting 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, costlier CGRP inhibitor-type drugs.

Kevin Pho: We’re speaking to Brian Worden. He’s an otolaryngologist. In the present day’s KevinMD article is “The shocking hyperlink between migraine and tinnitus.” Brian, let’s finish with some take-home messages that you just wish to depart with the KevinMD viewers.

Brian F. Worden: Positive. So, for the clinicians on the market, my message is: Please don’t underestimate the unfavourable results that intrusive tinnitus can have on our sufferers. Know that efficient tinnitus therapy does exist and that it’s changing into extra accessible as therapies are being migrated into the digital area. In case you don’t have a middle in your geographic space that’s providing high quality evidence-based tinnitus therapy, please take into account directing your sufferers to AlleviateTinnitus.com, the place they’ll entry a free, thorough tutorial workshop on the topic that I’ve put collectively, and that may get them plugged into some useful evidence-based therapy methods.

Kevin Pho: Brian, thanks a lot for sharing your perspective and perception. Thanks once more for approaching the present.

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