Prevalence of Pulsatile Tinnitus Among Patients With Migraine

Migraine management for the otolaryngologist

Objective

To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine.

Methods

Narrative review of available literature.

Results

Migraine disorder can be described as a spectrum of otologic manifestations, with vestibular migraine now recognized with fully-fledged diagnostic criteria. Otologic manifestations are theorized to be due, in part, to trigeminal innervation of the inner ear structures and calcitonin gene-related peptide (CGRP) expression within the labyrinth. Patients can experience vertigo, aural fullness, enhanced tinnitus, and hearing loss without the characteristic migraine headache, leading to under recognition of these symptoms as migraine-related. Meniere's disease, mal de débarquement syndrome, persistent postural perceptual dizziness, and recurrent benign paroxysmal positional vertigo have close associations to migraine and may exist on the migraine spectrum. Migraine treatment consists of two goals: halting acute attacks (abortive therapy) and preventing attacks (prophylactic therapy). Abortive medications include triptans, corticosteroids, anti-histamines, and anti-emetics. Pharmacologic prophylaxis in conjunction with lifestyle modifications can decrease frequency and severity of symptoms and include tricyclic antidepressants, calcium channel blockers, anti-epileptic medications, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, beta-blockers, gepants, and monoclonal antibodies to CGRP. Promising evidence is emerging regarding the ability of migraine medications to positively treat the various otologic symptoms of migraine.

Conclusion

Migraine disorder manifesting with primarily cochleovestibular symptoms can be challenging to diagnose and manage for practicing clinicians. Patients with various vestibulopathies that are closely related to migraine may benefit from migraine treatment. Lifestyle choices and prophylactic medications are key to satisfactorily preventing acute migrainous attacks and improve function.

Treatment of Stapedial Myoclonus as a Migraine-Related Phenomenon

OBJECTIVE

To describe a case series of patients with stapedial myoclonus (SM) whose conditions improved after prophylactic migraine treatment.

PATIENTS

We present seven cases of SM reported from a tertiary care neurotology clinic. All seven patients reported SM triggers similar to those of migraine headaches and suffered from concomitant headaches and/or vertigo, and were thus treated with a standard migraine protocol used at this neurotology clinic.

INTERVENTION

Prophylactic migraine treatment.

MAIN OUTCOME MEASURES

Reduction or resolution of SM.

RESULTS

In this series, seven patients with SM were included. Six of seven subjects were male (86%), with a mean age at presentation of 44 years. Four patients noted significant improvement in their symptoms, with a reduced frequency, duration, and intensity of their symptoms with the migraine regimen. Three patients experienced complete resolution of SM with their migraine treatment.

CONCLUSION

We report that treatment with prophylactic migraine treatment can provide long-term relief for patients with SM, which may suggest an etiological association between migraine and SM as well as a possible treatment for SM.

Vestibular and auditory manifestations of migraine

PURPOSE OF REVIEW

The purpose of this narrative review is to discuss current literature about vestibular migraine and other cochleovestibular symptoms related to migraine.

RECENT FINDINGS

Vestibular migraine affects 2.7% of the US population. Misdiagnosis is common. The pathophysiology is currently unknown but new research shows that calcitonin gene-related peptide, which is implicated in migraine headaches, is expressed in the audiovestibular periphery. A recent large-scale placebo-controlled trial looking at metoprolol for vestibular migraine was terminated early due to poor recruitment; however, at study completion, no differences were seen between treatment arms. Many other audiovestibular symptoms have been shown to be associated with migraine, including tinnitus, hearing loss, aural fullness, otalgia, and sinus symptoms. Migraine is also associated with risk for developing numerous otologic conditions, including Meniere's disease, vestibular loss, Benign Paroxysmal Positional Vertigo, and sudden sensorineural hearing loss. There is now some evidence that patients may experience fluctuating hearing loss and aural fullness without vertigo in association with migraine, which is called cochlear migraine.

SUMMARY

Migraine can cause a variety of audiologic and vestibular symptoms, and further research is required to understand how migraine affects the inner ear.

Identification of early-stage Meniere's disease as a cause of unilateral tinnitus

Introduction

Meniere's disease (MD) is characterized by episodic symptoms, including vertigo, hearing loss, and tinnitus.

Objectives

in this study, cases of unilateral tinnitus were investigated for MD.

Method

Twenty-two patients who presented with chronic unilateral tinnitus on puretone audiograms showing an average threshold better than 25 dB HL and thresholds in the lower frequencies worse than those in the higher frequencies by more than 10 dB were suspected to have early-stage MD and underwent electrocochleography (ECochG). Patients showing ECochG findings conclusive for MD were compared to a control group of patients presenting with chronic unilateral tinnitus on pure-tone audiograms showing an average threshold better than 25 dB and thresholds in the higher frequencies worse than those in the lower frequencies by more than 10 dB.

Results

Eighteen of the 22 patients included in this study showed elevated summating potential amplitude to action potential amplitude ratios in ECochG (suggestive of endolymphatic hydrops due to MD) and were followed up for 2 months; 14 of them experienced at least two attacks of vertigo or unsteadiness. In contrast, only one patient in the control group reported two or more attacks of vertigo or unsteadiness in the 2 month observation period. The incidence of this finding in the two groups was significantly different.

Conclusion

Patients with early-stage MD can present with only unilateral tinnitus. Thus, the addition of "pure-tone audiograms showing lower-frequency thresholds worse than higher-frequency thresholds" to the probable MD category in the globally.agreed diagnostic criteria for MD, may be useful.

Extraluminal Sigmoid Sinus Angioplasty: A Pertinent Reconstructive Surgical Method Targeting Dural Sinus Hemodynamics to Resolve Pulsatile Tinnitus

OBJECTIVES

1) To provide information on the treatment of pulsatile tinnitus (PT) with transtemporal extraluminal sigmoid sinus angioplasty (ESSA); and 2) to discuss the current clinical management of PT.

STUDY DESIGN

This was a retrospective study.

SETTINGS

Multi-institutional tertiary university medical centers.

PATIENTS

Fifty-four PT patients with transverse-sigmoid sinus enlargement and prominent transverse-sigmoid junction with or without sigmoid sinus wall anomalies or transverse sinus anomalies.

INTERVENTION

All patients underwent ESSA under local anesthesia.

MAIN OUTCOME MEASURES

Intraoperative discoveries and surgical resolution of PT, morphology, and computational fluid dynamics.

RESULTS

Fifty-three of the 54 (98%) patients experienced a significant reduction in, or complete resolution of, PT after ESSA. No major surgical complications occurred, except for one case where we observed a full collapse of the sinus wall. On average, this surgery reduced the cross-sectional area at the transverse-sigmoid junction by 61.5%. Our intraoperative discoveries suggest that sigmoid sinus wall anomalies may not be a definitive cause of PT. The transverse-sigmoid sinus system was significantly larger (in term of both cross-sectional area and volume) on the ipsilesional side compared with the contralesional side. Following ESSA, the vascular wall pressure and vortex flow at the transverse-sigmoid junction decreased considerably, and the flow velocity and wall shear stress increased significantly.

CONCLUSION

ESSA is a highly effective surgical technique for PT patients with transverse-sigmoid sinus enlargement and prominent transverse-sigmoid junction, regardless of whether they also have sigmoid sinus wall or transverse sinus anomalies. A large transverse-sigmoid system with prominent transverse-sigmoid junction is a predisposing factor for PT, and only by improving patients' intrasinus hemodynamics could PT be resolved efficiently. In cases without complete obstruction of venous return, ESSA is safe. No postoperative complications related to neurological disorders were observed.

Evaluation and treatment of pulsatile tinnitus associated with sigmoid sinus wall anomalies

OBJECTIVE

Describe clinical and radiographic features of sigmoid sinus wall anomalies (SSWA) associated with pulsatile tinnitus (PT) and determine factors predictive of response to surgery.

METHODS

Preoperative diagnostic imaging and treatment response were reviewed after surgical repair of 40 ears among 38 consecutive patients presenting with PT associated with SSWA who underwent transtemporal sinus wall reconstruction.

RESULTS

Twenty-three ears had isolated sigmoid sinus dehiscence, and 17 had diverticulum. The rates of transverse sinus stenosis (TSS) and empty sella, 66% and 32% respectively, were significantly higher than in historical controls (P = 0.02 and 0.001). Thirty-six out of 40 subjects (90%) had complete resolution of their PT following surgery, including all those with a diverticulum. For subjects with dehiscence alone without diverticulum, a favorable response to surgery was strongly associated with the presence of TSS (P = 0.01) and empty sella (P = 0.02).

CONCLUSION

Sigmoid sinus diverticulum and dehiscence are a clinically important cause of PT. Women of childbearing age with an elevated body mass index (BMI) are commonly affected, and there is a high rate of associated TSS and empty sella. Transtemporal sinus wall reconstruction has a high rate of success in appropriately selected patients. Patients with isolated sinus wall dehiscence without diverticulum, TSS, or empty sella are less likely to respond to transtemporal sinus wall reconstruction. These data imply a multifactorial cause of PT in at least some patients with SSWA.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:S1-S13, 2018.

Tinnitus Patients with Comorbid Headaches: The Influence of Headache Type and Laterality on Tinnitus Characteristics

Background

Both clinical experience and clinical studies suggest a relationship between tinnitus and headache. Here, we aimed to investigate the influence of comorbid headache type and headache laterality on tinnitus characteristics.

Method

The Tinnitus Research Initiative database was screened for patients of the Tinnitus Center of the University Regensburg who reported comorbid headaches. These patients were contacted to complete additional validated questionnaires. Based on these data, patients were categorized according to headache type and headache laterality, and their clinical characteristics were compared with tinnitus patients, who did not report comorbid headaches.

Results

Data from 193 patients with tinnitus and comorbid headaches were compared with those from 765 tinnitus patients without comorbid headaches. Tinnitus patients with comorbid headache have higher scores in tinnitus questionnaires, a lower quality of life and more frequently comorbidities such as painful sensation to loud sounds, vertigo, pain (neck, temporomandibular, and general), and depressive symptoms when compared with tinnitus patients without headaches. Both headache laterality and headache type interact with the degree of comorbidity with higher impairment in patients with left-sided and bilateral headaches as well as in patients with migraine or cluster headache.

Conclusion

The observed increased impairment in tinnitus patients with comorbid headache can be explained as an additive effect of both disorders on health-related quality of life. The more frequent occurrence of further comorbidities suggests a generally increased amplification of sensory signals in a subset of tinnitus patients with comorbid headaches.