The role of selective serotonin reuptake inhibitors and tricyclic antidepressants in addressing reduction of Meniere's disease burden: A scoping review

Objective

To assess the effect of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) in reducing vertigo, tinnitus, and hearing loss among patients with Meniere's disease (MD).

Data Sources

The following databases were utilized in this scoping review: Ovid Medline, PubMed-NCBI, CINAHL, Cochrane Library, Web of Science, and Clinicaltrials.gov.

Method

Studies were identified through the following search phrases: "serotonin specific reuptake inhibitors" OR "tricyclic antidepressants" AND "Meniere's disease." References from included manuscripts were examined for possible inclusion of additional studies.

Results

The literature search yielded 23 results, which were screened by three independent reviewers. Seventeen studies and three duplicates were excluded. An examination of references from the included studies yielded two additional publications. A total of four published studies assessing SSRIs and TCAs among 147 patients with MD were ultimately included. Four studies described significant reductions in vertigo attack frequency among patients treated with either SSRIs or TCAs compared to their pretreatment baseline. Three studies assessed the drugs' effects on hearing, of which none found a significant difference among patients treated with SSRIs or TCAs. One study found a significant decrease in patient-reported tinnitus following treatment with TCAs or SSRIs compared to their pretreatment baseline.

Conclusions

Data exploring SSRIs and TCAs among patients with MD suggests that these medications may reduce the frequency of tinnitus and vertigo, although there was significant heterogeneity in outcome reporting. There remains a need for larger-scale prospective studies that emphasize objective data to evaluate their effectiveness in reducing common MD symptoms.

Advances in diagnosis and treatment of vestibular migraine and the vestibular disorders it mimics

Dizziness is one of the most common chief complaints in both the ambulatory care setting and the emergency department. These symptoms may be representative of a broad range of entities. Therefore, any attempt at treatment must first start with determining the etiology. In this current perspective, we focus specifically on the diagnosis of and treatment of vestibular migraine, which is common and overlaps clinically with a variety of other diagnoses. We discuss the traditional treatments for vestibular migraine in addition to the recent explosion of novel migraine therapeutics. Because vestibular migraine can mimic, or co-exist with, a variety of other vestibular diseases, we discuss several of these disorders including persistent postural-perceptual dizziness, benign paroxysmal positional vertigo, post-concussive syndrome, Ménière's disease, and cerebrovascular etiologies. We discuss the diagnosis of each, as well as overlapping and distinguishing clinical features of which the reader should be aware. Finally, we conclude with evidence based as well as expert commentary on management, with a particular emphasis on vestibular migraine.

Meniere's disease is a manifestation of migraine

PURPOSE OF REVIEW

To discuss the theory that Meniere's disease (MD) is a variation of otologic migraine rather than an isolated inner ear condition.

RECENT FINDINGS

In contrast to the approximately 12% of the general population suffering from migraine headaches, 51-60% of patients with MD experience migraine headaches. While pathognomonic for MD, endolymphatic hydrops has also been identified in patients with vestibular migraine. Treatment with the integrative neurosensory rehabilitation approach (diet and lifestyle changes, magnesium and riboflavin supplementation, and when needed, prophylactic medication) to treat the underlying migraine process has been highly effective in patients with MD.

SUMMARY

MD can be understood as a manifestation of migraine such that patients with MD can be effectively treated with migraine therapies.

Correlation Between Laterality of Hearing Loss and Migraine Features in Menière's Disease

OBJECTIVES

The objective of this study is to understand whether the hearing loss laterality in Menière's disease (MD) correlates with migraine symptoms laterality such as headache, neck stiffness, and otalgia.

METHODS

We performed a retrospective review of prospectively obtained data on patients presenting between September 2015 and October 2021 with definite or probable MD. A custom-designed, comprehensive questionnaire was used to identify patients' migraine-related symptoms. The clinical and audiometric data were used to diagnose patients with definite or probable MD using criteria set by the American Academy of Otolaryngology-Head and Neck Surgery.

RESULTS

In total, 113 patients with definite or probable MD were included in the study. The mean age of the patients was 60 ± 15 years with no gender predominance (49.6% male and 50.4% female). A total of 57 (50%) patients were presented with headaches. Among the migraine headache cohort, headache and otalgia were on the same side as the MD ear affected by hearing loss. In addition, in patients who present with otalgia as the primary feature of headache, otalgia was more likely to be on the same side as the ear affected by the hearing loss.

CONCLUSIONS

The high prevalence of migraine symptoms on the same side of the ear affected by MD among this cohort could suggest a shared pathophysiology in both MD and migraine, possibly involving migraine-related changes in both the cochlea and vestibule.

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.

Management of Migraine-Associated Vestibulocochlear Disorders

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

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 migraine or Meniere's disease: a diagnostic dilemma

Meniere's disease (MD) represents one of the vertigo disorders characterized by triad symptoms (recurrent vertigo, fluctuating hearing loss, tinnitus or ear fullness). The diagnosis of MD relies on the accurate and detailed taking of medical history, and the differentiation between MD and vestibular migraine (VM) is of critical importance from the perspective of the treatment efficacy. VM is a highly prevalent vertigo condition and its typical symptoms (headache, vestibular symptoms, cochlear symptoms) mimic those of MD. Furthermore, the misdiagnosis in MD and VM could lead to VM patients mistakenly receiving the traumatic treatment protocol designed for MD, and sustaining unnecessary damage to the inner ear. Fortunately, thanks to the advances in examination technologies, the barriers to their differentiation are being gradually removed. These advances enhance the diagnostic accuracy of vertigo diseases, especially VM and MD. This review focused on the differentiation of VM and MD, with an attempt to synthesize existing data on the relevant battery of differentiation diagnosis (covering core symptoms, auxiliary tests [audiometry, vestibular tests, endolymphatic hydrops tests]) and longitudinal follow-up. Since the two illnesses are overlapped in all aspects, no single test is sufficiently specific on its own, however, patterns containing all or at least some features boost specificity.

Tympanostomy tube placement for pressure-sensitive vertigo

Objective

To evaluate tympanostomy tube placement in patients with pressure-sensitive vertigo.

Methods

Retrospective case series.

Results

Six patients with pressure-sensitive vertigo reported resolution of their vertigo and other vestibular symptoms after placement of the tympanostomy tubes. All recurrences of symptoms were due to either extrusion or plugging of the tubes. All patients fulfilled the criteria for vestibular migraine. None of the patients had superior canal dehiscence on imaging or precedent event that triggered the problem, and all had a negative fistula test.

Conclusion

Tympanostomy tube placement should be considered in selected patients with vertigo exacerbated by seemingly small changes in atmospheric pressure (e.g., just prior to thunderstorms, air travel, or travel to the mountains). By eliminating the capability of the tympanic membrane to sense changes in pressure with a tube, patients with pressure-induced vertigo (in the absence of perilymph fistula or superior canal dehiscence) may have relief of their symptoms.

Level of Evidence IV

Pathogenesis and Etiology of Ménière Disease: A Scoping Review of a Century of Evidence

Importance

Ménière disease is a rare chronic benign disorder of the inner ear with a natural history of multiple clinical phenotypes of variable severity and a tendency to burnout with time. Although multiple treatment modalities have been shown to improve the disease process-some adversely affecting cochleovestibular function-it remains uncertain whether one, several separate, or a combination of pathophysiologic mechanisms affect the disease process. A scoping review of the evidence underlying proposed pathophysiologic mechanisms of Ménière disease is needed to determine which processes are most likely to be etiopathogenic factors.

Observations

Of the 4602 relevant articles found through Embase, Ovid, and PubMed, 444 met inclusion criteria. The most common reported causes of Ménière disease were autoimmune or immune-mediated, genetic, or structural dysfunction of the inner ear. During the study period from inception to March 2021, etiologic theories shifted from structural dysfunction to autoimmune and genetic causes of Ménière disease.

Conclusions and Relevance

This scoping review found that Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years whose most commonly reported causes were structural dysfunction, immunologic damage, and genetic susceptibility. Recent studies have examined how autoinflammatory processes and vestibular migraine may be associated with Ménière disease. Large heterogeneity among studies may be explained by historical differences in the clinical understanding of the disease, as well as evolving intervention methodologies and practitioner expertise. Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years; therefore, future studies of reliable biomarkers of endolymphatic hydrops and real-time imaging are warranted to improve understanding and treatment.

Tinnitus and Subjective Hearing Loss are More Common in Migraine: A Cross-Sectional NHANES Analysis

OBJECTIVES

To investigate whether migraine is independently associated with tinnitus and subjective hearing loss (HL) in a large national database.

METHODS

The de-identified 1999 to 2004 National Health and Nutrition Examination Survey database was retrospectively queried for subjects aged 18 to 65. HL and tinnitus were subjectively reported by subjects.

RESULTS

A total of 12,962 subjects (52.9% female) with a mean age of 38.1 ± 14.6 years were included. This consisted of 2,657 (20.5%), 2,344 (18.1%), and 2,582 (19.9%) subjects who had migraine, subjective-HL, and tinnitus, respectively. In patients with tinnitus or subjective-HL, migraine was reported in 35.6% and 24.5%, respectively. Migraineurs were more likely to have subjective-HL (25.0% vs. 16.6%, p < 0.001) and tinnitus (34.6% vs. 16.9%, p < 0.001) compared to the nonmigraineurs. This corresponded to migraine having an odds ratio of 1.5 (95% confidence interval [CI] 1.3-1.7, p < 0.001) and 2.2 (95% CI 2.0-2.4, p < 0.001) for subjective-HL and tinnitus, respectively. After adjusting for confounders, subjective-HL (odds ratio [OR] = 1.2, 95% CI 1.1-1.4, p = 0.003), tinnitus (OR = 2.1, 95% CI 1.9-2.3, p < 0.001), and neck pain (OR = 4.0, 95% CI 3.6-4.5, p < 0.001) were more common in migraineurs. Among migraineurs, a higher proportion of those with tinnitus also had subjective-HL compared to those without tinnitus (40.0% vs. 15.3%, p < 0.001), and a higher proportion of those with subjective-HL also had tinnitus compared to those without HL (58.1% vs. 27.3%, p < 0.001).

CONCLUSIONS

This study suggests an independent association between migraine with subjective-HL and tinnitus. Otologic migraine, which is the effects of migraine on the ear, may be partly responsible for the link between HL, tinnitus, neck pain, and migraine.

Cochlear implantation in patients with Meniere's disease: A systematic review

BACKGROUND

Meniere's disease (MD) is an idiopathic disorder of the inner ear, which manifests as cochleo-vestibular dysfunction. Hearing loss will progress to a profound levelin a subset of patients with MD, and vestibular interventions can independently cause loss of hearing. The aim of this study was to systematically review the published literature describing the safety and efficacy of CI in patients with MD.

MATERIALS AND METHODS

A systematic literature review was conducted in accordance PRISMA guidelines to identify articles that assessed at least one functional outcome in patients with MD who underwent CI. Demographic information, disease history, MD symptoms, outcomes measures, and complications related to CI were extracted from included studies.

RESULTS

In total, 17 studies were included, and 182 patients with MD underwent CI. The weighted-mean age was 61.9 years (range 27-85). Study objective and methodology varied, and there was significant heterogeneity in CI outcome measures reported. In total, 179 (98.3%) of 182 patients reported objective improvements in at least one hearing metric after CI. A total of 69 patients (37.9%) reported vertigo or severe dizziness prior to CI, compared to 22 patients (15.4%) postoperatively. Two studies reported significant reductions in postoperative Tinnitus Handicap Inventory score (THI). Quality of life assessments varied between studies. Complications rates were low with only nine patients (4.9%) reporting a serious CI-related complication.

CONCLUSIONS

This systematic review evaluated 17 studies describing the safety and efficacy of CI in patients with MD and encountered many challenges due to small sample sizes, and heterogeneity in study design and outcomes measured. Despite these limitations, this study of 182 patients is to the best of our knowledge the largest systematic review evaluating the safety and efficacy of CI in MD. The results of this study support the need for a standardized approach to evaluating outcomes of CI in patients with MD in future studies.

Treatment of Long-term Sudden Sensorineural Hearing Loss as an Otologic Migraine Phenomenon

OBJECTIVES

To describe a cohort of patients presenting with long-term sudden sensorineural hearing loss (SSNHL) treated with prophylactic migraine and intratympanic steroid therapy.

METHODS

Patients presenting to a neurotology clinic at least 6 weeks from SSNHL onset were included. All patients received migraine prophylactic medication (nortriptyline, topiramate, and/or verapamil) and lifestyle changes for at least 6 weeks, as well as intratympanic steroid injections, if appropriate.

RESULTS

Twenty-one patients (43% female) with a mean age of 64 ± 11 years who presented 9 ± 8 months (median = 5) from symptom onset were included. Posttreatment hearing thresholds were significantly improved compared with pretreatment thresholds at 500 Hz (49 ± 19 dB versus 55 ± 20 dB, p = 0.01), 1000 Hz (52 ± 19 dB versus 57 ± 21 dB, p = 0.03), low-frequency pure-tone average (53 ± 15 dB versus 57 ± 17 dB, p = 0.01), and speech-frequency pure-tone average (57 ± 13 dB versus 60 ± 15 dB, p = 0.02). Posttreatment word-recognition-score (WRS) and speech-recognition-threshold (SRT) were also significantly improved (45 ± 28% versus 70 ± 28% and 57 ± 18 dB versus 50 ± 16 dB, respectively, both p < 0.01). Notably, ≥15% improvement in WRS and ≥10 dB improvement in SRT was observed in 13 (68%) and 8 (40%) patients, respectively. Of the 11 patients who presented with initial < 50% WRS, 8 (73%) had improved posttreatment >50% WRS with an average improvement of 39 ± 9%.

CONCLUSIONS

Migraine medications in addition to intratympanic steroid injections significantly improved SRT and hearing frequencies in 40% and 29% of SSNHL patients, respectively, while significant WRS recovery was observed in most (68%) patients. This suggests SSNHL may be an otologic migraine phenomenon, which may be at least partially reversible even after the traditional 30-day postonset window.

The clinical characteristics and anatomical variations in patients with intractable unilateral Meniere's Disease with and without migraine

BACKGROUND

Migraine is more common in Meniere's disease patients, who have some certain anatomical variations. But there are limited studies focusing on the anatomical variations in patients with Meniere's disease and migraine.

OBJECTIVE

To explore the clinical and anatomical features in Meniere's disease patients with and without migraine, determining whether the coexistence of migraine can be used as a basis for clinical subtyping of Meniere's disease.

METHODS

Ninety-five Meniere's disease patients and ninety-five healthy subjects matched with age, sex were selected. A detailed questionnaire based on the diagnosis criteria of Meniere's disease and migraine was designed. According to the CT scan, we divided the mastoid cell system of all the subjects into two types: well-pneumatization type and poor-pneumatization type. Meanwhile, the shortest distance between the sigmoid sinus and the posterior wall of the external acoustic canal was measured.

RESULTS

Compared with those without migraine, Meniere's disease patients with migraine had a higher female comorbidity, poorer mastoid pneumatization, shorter distance between the sigmoid sinus and posterior wall of the external acoustic canal, longer history, higher frequency of vertigo attacks and better average hearing threshold.

CONCLUSIONS

In our study, anatomical features as well as several clinical manifestations were proved to differ significantly between Meniere's disease patients with and without migraine, indicating the coexistence of migraine may be one standard for the clinical subtyping of Meniere's disease.

Vertigo without cochlear symptoms: vestibular migraine or Menière disease?

BACKGROUND

Menière's disease (MD) is an inner ear disorder due to raised endolymphatic pressure (hydrops), characterized by cochlear symptoms associated with episodic vertigo. In delayed hydrops, vertigo attacks begin long after the onset of a hearing loss. Few were published on MD in which the onset of vertigo precedes cochlear symptoms by several months. Vestibular migraine (VM) is also a cause of episodic vertigo and an association between migraine and MD was proposed. Purpose of our retrospective work was to assess clinical features associated with MD in which vertigo precedes by months cochlear symptoms.

METHODS

Our sample was composed by 28 subjects reporting episodic vertigo accompanied by migrainous headache or photo-phonophobia, without cochlear symptoms at onset; during follow-up, all patients developed cochlear symptoms leading to a diagnosis of MD. Results of bedside examination were compared with those of 48 VM subjects with diagnosis of VM confirmed in the follow-up. All subjects performed a bedside examination, including head-shaking, positional, and skull vibration test (SVIN).

RESULTS

SVIN was more frequent in MD, while positive positional test in VM. In the entire group of 72 subjects, migrainous headache during vertigo and positive positional test were correlated with a final diagnosis of VM.

CONCLUSIONS

Our data are not inconsistent with the hypothesis that in patients reporting only photo-phonophobia during vertigo attacks and with a positive SVIN, the clinical manifestations may be predictive for evolution toward a MD, while migrainous headache and positive positional tests more frequently are correlated to VM.

[Qualitative Study on the Experience of Patients with Meniere Disease]

PURPOSE

The purpose of this study was to understand and describe the experiences of patients with Meniere disease.

METHODS

Data were collected from February 19, 2019, to February 5, 2020, through individual in-depth interviews with 13 Meniere patients. Verbatim transcripts were analyzed using Colaizzi's phenomenological analysis.

RESULTS

The experiences of patients with Meniere disease were clustered into the following four themes from 22 meaning units: 1) Complex unfamiliar symptoms that shatter both balance of the body and peace of the heart; 2) A disease that health professionals and medical treatment cannot cure; 3) Suffering hardships that cannot be understood by non-Meniere's sufferers; and 4) Making daily efforts to become healthier. Meniere's symptoms are life-shattering and depressing because they are neither visible nor easily curable. Over time, as they accepted the reality of living with the disease, the participants would shift their focus from complete symptomatic cure to leading a healthy and more balanced life.

CONCLUSION

This study shows that Meniere disease has a pervasive impact on all aspects of the patients' lives. Patients are prone to experiencing restrictions in their social functioning and activities. They also experience psychosocial problems due to the unseen nature of their symptoms. This study elucidates the experiences of Meniere patients and the need for nursing intervention to help improve their quality of life and ability to self-manage. Lastly, this study shows the need for a coordinated interdisciplinary approach to raising public awareness of the disease.

Adjuvant Migraine Medications in the Treatment of Sudden Sensorineural Hearing Loss

OBJECTIVES/HYPOTHESIS

To examine the hearing outcomes of patients with sudden sensorineural hearing loss (SSNHL) treated with oral and intratympanic (IT) steroid only or a combination of steroid and migraine treatment. Our hypothesis was that adjuvant migraine medications may improve outcomes in SSNHL.

METHODS

A retrospective chart review at a tertiary otology center was conducted to identify patients with SSNHL who received oral steroid and IT dexamethasone injection(s) with or without migraine medications (a combination of nortriptyline and topiramate).

RESULTS

A total of 47 patients received oral steroid and IT dexamethasone injection(s) only, and 46 patients received oral steroid and IT dexamethasone injection(s) as well as migraine lifestyle changes plus a combination of nortriptyline and topiramate. There were no significant differences in demographics and baseline audiometric data between the two groups. Both groups demonstrated improvements in pure tone average (PTA) and hearing thresholds at 250 Hz and 8000 Hz posttreatment. However, compared to steroid-only group, the adjuvant migraine medications group had significantly greater improvements in hearing thresholds at the lower frequencies (250 Hz, 500 Hz, 1000 Hz). Patients in the latter cohort also had greater improvement in PTA (P = .01) and received fewer IT injections (P = .04) PTA improvement of ≥ 10 dB was observed in 36 patients (78%) in the adjuvant migraine medications group and 22 patients (46%) in the control group (P < .001).

CONCLUSION

In multimodal treatment of SSNHL, supplementing oral and IT steroid with migraine medications may result in greater improvements in lower frequency hearing thresholds and PTA. Furthermore, adjuvant migraine treatment can lead to decrease in number of IT injections, thus reducing procedure-related risks and complications.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E283-E288, 2021.

Efficacy of Multi-Modal Migraine Prophylaxis Therapy on Hyperacusis Patients

OBJECTIVES

To evaluate the efficacy of a multi-modal migraine prophylaxis therapy for patients with hyperacusis.

METHODS

In a prospective cohort, patients with hyperacusis were treated with a multi-modal step-wise migraine prophylactic regimen (nortriptyline, verapamil, topiramate, or a combination thereof) as well as lifestyle and dietary modifications. Pre- and post-treatment average loudness discomfort level (LDL), hyperacusis discomfort level measured by a visual analogue scale (VAS), and scores on the modified Khalfa questionnaire for severity of hyperacusis were compared.

RESULTS

Twenty-two of the 25 patients (88%) reported subjective resolution of their symptoms following treatment. Post-treatment audiograms showed significant improvement in average LDL from 81.3 ± 3.2 dB to 86.4 ± 2.6 dB (P < .001), indicating increased sound tolerability. The VAS discomfort level also showed significant improvement from a pre-treatment average of 7.7 ± 1.1 to 3.7 ± 1.6 post-treatment (P < .001). There was also significant improvement in the average total score on modified Khalfa questionnaire (32.2 ± 3.6 vs 22.0 ± 5.7, P < .001).

CONCLUSIONS

The majority of patients with hyperacusis demonstrated symptomatic improvement from migraine prophylaxis therapy, as indicated by self-reported and audiometric measures. Our findings indicate that, for some patients, hyperacusis may share a pathophysiologic basis with migraine disorder and may be successfully managed with multimodal migraine prophylaxis therapy.

A hypothetical proposal for association between migraine and Meniere's disease

Meniere's disease (MD) is a chronic condition affecting the inner ear whose precise etiology is currently unknown. We propose the hypothesis that MD is a migraine-related phenomenon which may have implications for future treatment options for both diseases. The association between MD and migraine is both an epidemiological and a mechanistic one, with up to 51% of individuals with MD experiencing migraine compared to 12% in the general population. The presence of endolymphatic hydrops in those with MD may be the factor that unites the two conditions, as hydropic inner ears have an impaired ability to maintain homeostasis. Migraine headaches are theorized to cause aura and symptoms via spreading cortical depression that ultimately results in substance P release, alterations in blood flow, and neurogenic inflammation. Chronically hydropic inner ears are less able to auto-regulate against the changes induced by active migraine attacks and may ultimately manifest as MD. This same vulnerability to derangements in homeostasis may also explain the common triggering factors of both MD attacks and migraine headaches, including stress, weather, and diet. Similarly, it may explain the efficacy of common treatments for both diseases: current migraine treatments such as anti-hypertensives and anti-convulsants have shown promise in managing MD. Though the etiology of both MD and migraine is likely multifactorial, further exploration of the association between the two conditions may illuminate how to best manage them in the future. MD is likely a manifestation of cochleovestibular migraine, which occurs as a result of migraine related changes in both the cochlea and vestibule.

Successful treatment of a child with definite Meniere's disease with the migraine regimen

Emerging evidence suggests substantial overlap between the symptoms of Meniere's disease (MD) and migraine-related cochlear/vestibular disorders. We report a 5-year-old girl with a 6-month history of left-sided hearing loss followed by daily episodes of vertigo, headache, and vomiting who met the criteria for definite MD. The patient became symptom-free and gained near normal hearing levels after starting on a 6-week migraine diet/lifestyle regimen with riboflavin and magnesium. We believe that the symptoms of MD may be primarily due to a vestibular migraine phenomenon. Pediatric MD patients may benefit from migraine lifestyle/dietary changes with control of both cochlear and vestibular symptoms.