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Treating Otologic Conditions as Migraines
Taylor Spurgeon-Hess • Sep 14, 2022 • 34 hits
While otolaryngologists frequently diagnose patients with conditions such as Ménière’s disease, sudden sensory hearing loss, and persistent postural-perceptual dizziness (PPPD), often the diagnosis is not connected to any other condition. However, Dr. Djalilian believes that many of the otologic conditions mentioned above may be manifestations of migraines. By treating these conditions with the standard migraine regimen as opposed to treating them with their typical regimen alone, patients may find increased symptom relief.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Some otologic symptoms that may indicate that migraines are the underlying issue include dizziness with eye movement, visual motion sensitivity, and significant hyperacusis.
• To treat Ménière’s disease as migraines, otolaryngologists can start the patient on the migraine diet, without sodium restriction, and may prescribe nortriptyline for frequent vertigo as well.
• In addition to the typical oral and intratympanic steroids, migraine medications can be given to sudden sensory hearing loss patients that present with unilateral neck stiffness.
• Persistent postural-perceptual dizziness patients can be treated with topiramate and nortriptyline, but they should also attempt to reduce triggers, such as stress, in order to find maximum relief.
Table of Contents
(1) Otologic Symptoms Indicative of Migraines
(2) Treating Otologic Conditions: Meniere’s Disease and Sudden Sensory Hearing Loss
(3) Addressing Persistent Postural-Perceptual Dizziness
Otologic Symptoms Indicative of Migraines
Because of the atypical nature of the migraine, Dr. Djalilian started to notice common themes among patients with various conditions. One indication that an otologic condition may be migraine related revolves around the triggers a patient experiences. If the triggers are the same as typical migraine triggers, then migraines may be the actual underlying cause. Other otologic symptoms indicative of migraines include visual motion sensitivity and significant hyperacusis. Taking a detailed history and asking about migraine related symptoms, such as light and sound sensitivity or chronic sinus headaches, can aid in connecting a seemingly unrelated diagnosis to migraine as the underlying cause.
[Walter Kutz MD]
So what initially gave you the idea that many otologic symptoms are manifestations of migraines?
[Hamid Djalilian MD]
Yeah, that's a good question. I mean, the problem was I noticed that people would ask me questions about dizziness and I was a fellow at the time. And, I was supposed to know the answers to these questions and I couldn't answer the questions and people would say, if I'm moving my head quickly, I feel a little dizzy. Or if I look at things and move a lot, it makes me dizzy. And I just couldn't figure out what it was. And so, I started looking for a common theme amongst these patients. And it was sort of when the Meniere’s patient actually told me that they're moving their eyes and they get dizzy when they're watching TV, it just made me think this cannot be a peripheral problem because you don't stimulate the vestibular organ by just moving your eyes if your head is not moving. So this must be something centrally.
And then from there sort of keeping track of all these sort of common themes from the patients that would describe these conditions. I was at the American Neurotology society meeting, I think 2008 or nine. And there was a very good panel that John Carey had put on and there were several neurologists who spoke at that point. And it sort of opened my eyes to this sort of atypical nature of migraine. And I, sort of being a migraine sufferer myself, I started being a little more observant on what I was experiencing, and noticed again, the same common theme that the patients are talking about. So that's sort of how it all started and it sort of evolved over time to recognize that there were a lot of other conditions where the triggers are the same as a migraine. And so it made me think that these are probably all migraine related. And so we started treating them with migraine medications and lifestyle changes and they got better. And so that's how we got to this place.
[Walter Kutz MD]
Interesting. Yeah. I mean, I see many patients with similar complaints and other otologic complaints that I have a hard time really identifying what exactly is going on. And it's very frustrating for I think especially the patient, but it is for me as well. So how do you approach a patient that comes in with kind of classic Meniere’s disease? They have that unilateral fluctuating hearing loss, episodic vertigo, and maybe they don't even have a history of headaches. How do you address these patients? How do you treat them? What is kind of your thought process?
[Hamid Djalilian MD]
Sure. So I used to think of Meniere's as a pure inner ear disorder. And I would treat it with diuretics, like most other people do nowadays. And then, I started seeing over time, these patterns of problems that people describe, one of which is really the visual motion sensitivity, the significant hyperacusis that some of them have. And I just thought these are not peripheral problems. They sound like central problems. And so it made me think that there was probably something to it. And then we started looking at all the patients who presented with Meniere’s, sort of looking for migraine features in them. And so asking them very detailed questionnaires about not only all the sort of diagnostic criteria for migraine, headaches, but also asking them a lot of the typical things we see in migraine, like visual and motion sensitivity, sound sensitivity, light sensitivity, about their family history, other migraine related conditions, like chronic sinus headaches, ice cream headaches, things like that.
And we noticed that basically, if you take a population of Meniere's disease, about 50% of them approximately, they fulfill the criteria for migraine headaches. And then if you take the other 50% and just look at whether they have migraine features or if they have a first degree relative with migraine, things like that, then that would cover essentially a hundred percent of all the patients with Meniere's disease have some kind of migraine related issue.
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Treating Otologic Conditions: Meniere’s Disease and Sudden Sensory Hearing Loss
When treating Ménière’s disease as migraines, it is important to first spend adequate time discussing this with the patient as they have likely been pushed to a different line of treatment for many years. These patients then start on the migraine diet, but without restrictions on their sodium intake. Patients should avoid glutamate and tyramine, should increase their water intake, and may be encouraged to supplement their diet with magnesium and vitamin B2. For frequent vertigo, nortriptyline may be added to the treatment plan as well. For sudden sensory hearing loss patients that present with unilateral neck stiffness, migraine medications such as topiramate and nortriptyline may be added in combination with the typical oral and intratympanic steroids.
[Hamid Djalilian MD]
So what I do nowadays, and probably have been doing for quite a while now is I will first discuss migraine. I used to try to tease out a headache history and things like that. And I really, over time I realized these patients respond so well to migraine treatment. I don't even need to look for it. So I don't actually ask about headaches anymore. I will occasionally ask them about neck stiffness. Sometimes I ask them some questions more to convince the patient because the patients come to me, they've seen other neurologists. They've been treated with the standard treatment and they haven't gotten better. And so then I'll tell them, oh, this is what the issue is. And try to really convince them because sometimes, they've been treating with someone for five, ten years, and then I come up with a completely different theory of what they have. And so the patients don't always believe you. So I have to kind of spend a little extra time making sure that the patient buys into what I'm telling them, so they will follow the treatment. Okay. And what I do tell them to follow the migraine diet. Now, there's obviously a significant overlap between the migraine and Meniere’s diet. But the one thing I do not restrict them on is sodium. So I tell them they can have as much sodium as they want pure sodium like salt. But they need to drink a lot of water. And so I tell patients that they need to drink two liters of water per day. If they have a very salty meal, they just need to drink more water because migraine is really related to hydration rather than, to, salt per se. And then the other factors such as glutamate and tyramine, which happen to be in very high sodium containing food, I tell them to avoid. And then I usually start them on magnesium and vitamin B2. And then, if their vertigo is frequent, I'll start them on nortriptyline, most commonly to start with, but depending on what their other medications are, I may start them on topiramate or verapamil potentially as well. I must say that I, probably in the last 10 years, I’ve maybe given diuretics one time, and that was really because everything else failed.
And betahistine I actually don't prescribe, as you probably know, betahistine has been evaluated by the FDA. It was approved by the FDA originally back in the sixties, but then the FDA actually withdrew their approval because they did not find adequate data. And then they applied for FDA approval again in the last 20 years, sometime I think, and the FDA rejected them. So the data on betahistine is not very strong, although some patients will anecdotally tell you that they get better with it. I don't prescribe it just because it's expensive also, and difficult for patients to get because it's not FDA approved, so they have to get it from Canada or a compounding pharmacy, which makes it very expensive.
[Walter Kutz MD]
That's interesting that I think most neurotologist otolaryngologists probably think diuretics as the first-line treatment. And you're saying, “Hey, no, let's treat this as migraines right off the bat.” I, in my practice, have been reading your studies and your work. I sorta think of migraine treatments as my second line, after diuretics and betahistine. That's a very interesting approach and is sounds like it’s worked very well for your practice, especially if you're seeing some of the most difficult patients that have failed many other treatments from other otolaryngologists and neurotologists. So nortriptyline, that's kind of my first line as well.
[Hamid Djalilian MD]
So, again, I started noticing these patients with sudden hearing loss coming in and describing very classic, either classic migraine or atypical migraine symptoms, leading up, or right at the time of onset, a lot of times patients will have, they'll have sometimes paresthesias of the scalp, or they'll have this unilateral neck stiffness, which is another migraine related phenomenon. And so they describe that at the time of their sudden loss or, uncommonly, they'll have a headache right at the time as well, but most commonly they'll feel paresthesias around the ear or the head or the neck stiffness, or sometimes sinus pain, things like that. And so, I started a few years ago, treating all the sudden hearing loss patients, in addition to the oral and intratympanic steroids that I start right away, I started giving them nortriptyline and topiramate as well in combination. And, we actually then studied our patients over a period of time. And so we had the sort of historical control from like the year before I started doing it and then the ones that I treated like this. And then we had, I think about 46 or 47 patients per group. And we found that the patients treated with the additional migraine regimen have better low-frequency hearing outcomes. And so, we published, I think maybe a year or two ago or something like that. So now, I mean, I've been doing it routinely probably for the last five, six years or so, on all of the sudden hearing loss patients. And I always thought that they had a better outcome, but then, I told my postdoc, I said, let's study this and make sure I'm not overtreating anybody. And so then we looked at it. And so then the data definitely showed that the low-frequency hearing outcome was much better.
Addressing Persistent Postural-Perceptual Dizziness
Like Ménière’s disease and sudden sensory hearing loss, persistent postural-perceptual dizziness (PPPD) has been linked to migraines. PPPD can be compared to mal de debarquement syndrome (MDDS) but occurs without a trigger. The hallmark symptom of visual motion sensitivity presents in both PPPD and migraines. While some literature points to successful PPPD treatment with an SSRI, often the migraine treatment, including nortriptyline and topiramate, can provide the same or increased relief according to Dr. Djalilian. Ultimately, relieving triggers, namely chronic stress, can quickly help to decrease symptoms in patients with PPPD.
[Walter Kutz MD]
What are your thoughts on persistent postural-perceptual dizziness, also treating PPPD? Do you have any thoughts on that? Differentiating that from vestibular migraines, do you think PPPD is migraines as well?
[Hamid Djalilian MD]
Yeah. And we actually have two papers coming up. One is on just the, again, prevalence of migraine in the PPPD population and then treating the PPPD population with migraine regimen. I don't know where they are in the process, but they're under review. I think, maybe one of them is under revisions or something.
PPPD, a lot of the overlap with the sort of the migraine symptoms, so visual motion sensitivity. We wrote a paper on mal de debarquement syndrome or MDDS or disembarkment syndrome, a few years ago showing again, migraine is very common and then they responded really well to migraine treatment. And I tell them really PPPD is effectively an MDDS without a trigger, that happens. So MDDS obviously, it happens after a prolonged boat ride or a plane ride, whereas PPPD occurs more spontaneously and is usually associated with most commonly with a vertigo episode that starts it. And, a lot of the symptoms are really migraine type symptoms, again, visual motion sensitivity being the hallmark of PPPD. And we've had really good results in general, treating these patients. Now do we fix everyone? No, I mean, I wish we could. I mean, there are patients that, really, it's hard to overcome some of their triggers. I mean, probably the most difficult ones are patients who take care of a spouse who is ill or has Alzheimer or something where their sleep is interrupted everyday, they have chronic stress. And some of those are just unfortunately, very difficult to fix. And, interestingly is that a lot of these patients get better once the spouse has passed away and that sort of stress is relieved. Their sleep is back to normal. The problem sort of goes away. So, I mean, sometimes we can't fix everyone. I mean, that's definitely true, but we can help a vast majority of them with the migraine regimen in the PPPD population.
[Walter Kutz MD]
A lot of the literature shows that SSRIs are successful for treating PPPD. It sounds like you lean towards nortriptyline and Topamax, similar to how you treat vestibular migraines. What are your thoughts about an SSRI for the treatment of PPPD?
[Hamid Djalilian MD]
Yes. I think a lot of literature is on venlafaxine or Effexor. I don't use it very commonly. Sometimes the patient will come in insisting that they want that. And so I will give it to them, but generally speaking, I will start with just the routine nortriptyline, topiramate. I mean, when you think about really nortriptyline, I mean, it is a tricyclic antidepressant, but its effect is like an SSRI/SNRI, which is what venlafaxine is. And so I usually just start with what I use most commonly and I know the side effect profile. I know all of the intricacies of it. I think it's good to become familiar with the sort of meds, which probably more than 95% of patients are going to be on one of three medications, which is nortriptyline, topiramate, or verapamil.
I will use paroxetine as well, probably in those that I think have a lot of the stress component or sleep component, but they can't take a TCA because of cardiac related issues. So, those are probably my go-to meds. I do use venlafaxine, but probably much less commonly. I think the etiology, at least based on the patient's history and our papers that are going to be coming out hopefully soon, are that these are migraine related problems. That PPPD is a migraine related issue and it really treating the migraine helps them. I think a lot of times when studies are done, they are done because you try to control it. So you say this person gets this medicine at this dose and this group just gets a single pill. And the problem with migraine, it's a lot more complex than that. You need to sort of do the lifestyle changes and you need to do dose escalation, which very few migraine trials do, or PPPD trials I’d say. So, I don't subscribe to the one pill, one dose regimen of treatment, because I think everyone's different and people's sensitivity and tolerance is different and all that stuff. So I try to tell patients, it's not very simple like I can just give you a single pill and that's going to fix it. It might take two or three pills. It might take a couple of months to get to these doses. You need to do the lifestyle change. But if we do all this stuff, I can tell you with high degree of certainty, you will get better. And sometimes I should say that it's really important that we communicate to the patient, that we know what you have, and we know we can get you better. And that a lot of times has a pretty significant, positive psychological impact on the patient because they've seen several physicians and they've told them, I don't know what you have or, there's nothing else I can do for you. And so then there's this sort of despair, and stress and depression that comes from that. And I think, giving them the confidence really, I think helps sort of turn the page on and trying to get them better.
Dr. Hamid Djalilian
Dr. Hamid Djalilian is the director of Otology, Neurotology, and Skull Base Surgery at UC Irvine in California.
Dr. Joe Walter Kutz
Dr. Joe Walter Kutz is a neurotologist and Professor of Otolaryngology and Neurosurgery at the University of Texas Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, May 24). Ep. 60 – Otologic Manifestations of Migraine [Audio podcast]. Retrieved from https://www.backtable.com
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