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BackTable / ENT / Podcast / Episode #60

Otologic Manifestations of Migraine

with Dr. Hamid Djalilian

In this episode of BackTable ENT, Dr. Walter Kutz interviews otologist Dr. Hamid Djalilian about the link between the hearing / vestibular disorders and migraines.

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Otologic Manifestations of Migraine with Dr. Hamid Djalilian on the BackTable ENT Podcast)
Ep 60 Otologic Manifestations of Migraine with Dr. Hamid Djalilian
00:00 / 01:04

BackTable, LLC (Producer). (2022, May 24). Ep. 60 – Otologic Manifestations of Migraine [Audio podcast]. Retrieved from

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Podcast Contributors

Dr. Hamid Djalilian discusses Otologic Manifestations of Migraine on the BackTable 60 Podcast

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 discusses Otologic Manifestations of Migraine on the BackTable 60 Podcast

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.


In this episode of BackTable ENT, Dr. Walter Kutz interviews otologist Dr. Hamid Djalilian about the link between the hearing / vestibular disorders and migraines.

First, Dr. Djalilian shares how he discovered the connection between Meniere’s disease and migraines when he noticed that many Meniere's patients described migraine-like triggers and migraine-like symptoms. He then decided to treat his Meniere’s patients with migraine medications, such as nortriptyline, topiramate, and verapamil and encouraged them to follow migraine diets. He found that many patients’ symptoms and hearing improved after this regimen. This discovery led him to conduct multiple novel research studies about using migraine medications to restore hearing and balance in Meniere’s patients.

Next, Dr. Djalilian describes his migraine medication dosage for Meniere’s patients. He starts patients off with 10 mg of nortriptyline for 2 weeks and then increases the dosage by 10 mg every week for six weeks. For patients with very frequent vertigo, he will start the patients on 25 mg of nortriptyline for 2 weeks and then increase the dosage by 25 mg every 2 weeks for 6 weeks. For topiramate, he will start the patient on 25 mg and increase the dosage by 25 mg every week for 6 weeks.

Additionally, he recommends that patients take Vitamin B2 and magnesium supplements. He also emphasizes that lifestyle modifications (sleep hygiene, diet, hydration, stress management, etc.) are the most important part of resolving migraines and Meniere’s disease. He encourages all his patients to keep a journal in order to find their migraine triggers in order to resolve their symptoms more effectively while on medication.

Next, he explains how he trains advanced practice providers, like NPs and PAs, to help manage his high volume of Meniere’s patients. He makes sure they are comfortable with taking a comprehensive history and explaining medications and their side effects. During the time they spend with him, he also provides them with personal talks, handouts, and book recommendations. Finally, he trains them to perform intratympanic steroid injections. Working with NPs and PAs allows him to care for patients more efficiently and frees him up to see complicated patients.

Finally, the doctors discuss Dr. Djalilian’s new research about the link between persistent postural perceptual dizziness and migraine as well as the ability of migraine medication to treat the former.


Sarna B, Abouzari M, Lin HW, Djalilian HR. A hypothetical proposal for association between migraine and Meniere's disease. Med Hypotheses. 2020 Jan;134:109430. doi: 10.1016/j.mehy.2019.109430. Epub 2019 Oct 12. PMID: 31629154; PMCID: PMC6957735.

“Heal Your Headache” by David Buchholz

Transcript Preview

[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, 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.

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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A physician conducts an exam to determine the patient’s otologic conditions

Treating Otologic Conditions as Migraines

An otolarygologist explains treatment options for a patient with migrianes including nortriptyline and topiramate.

Nortriptyline & Topiramate For Migraines


Dizziness Condition Overview
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