.png){kind=small}
.png){kind=small}
BackTable / ENT / Article
Migraine & Tinnitus: Causes, Triggers & Other Atypical Migraine Symptoms
Megan Saltsgaver • Updated Jan 15, 2025 • 33 hits
Tinnitus, often described as a ringing, buzzing, or hissing sound in the ears, is a condition that affects millions of people worldwide. Traditionally, it has been attributed to damage or dysfunction in the auditory system but recent research has highlighted a surprising connection between tinnitus and migraine-related processes. Understanding this link between migraines and tinnitus not only broadens treatment possibilities but also provides hope for those who struggle with this often debilitating condition.
Otolaryngologist Dr. Hamid Djalilian explains the recent advancements in our understanding of tinnitus and shares his view on how we should approach other atypical migraine symptoms. 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
• Tinnitus is commonly thought to result from inner ear damage or nerve dysfunction, causing persistent ringing or buzzing sounds. Recent research suggests that tinnitus, especially fluctuating or intermittent types, may be linked to migraine-related processes, including triggers like stress, poor sleep, and dietary factors.
• Eliminating or reducing triggers like caffeine, alcohol, and monosodium glutamate (MSG) can significantly reduce tinnitus symptoms, especially when combined with proper hydration and regular meals.
• Hormonal changes and environmental overstimulation (e.g., loud noises, intense exercise) can exacerbate tinnitus, requiring careful management of exposure.
• Poor sleep quality and high stress levels are major contributors to tinnitus flare-ups, and addressing these issues is the first step in treatment.
• Successful management often combines lifestyle changes, dietary modifications, and, when needed, medications, with patient education playing a key role in long-term relief.
Table of Contents
(1) Pathophysiology of Tinnitus & Connection to Migraines
(2) Migraine & Tinnitus Triggers
(3) Other Atypical Migraine Symptoms
Pathophysiology of Tinnitus & Connection to Migraines
Dr. Hamid Djalilian challenges traditional views on tinnitus pathophysiology, which often attribute the condition to the loss of inner ear cells or the synapses between hair cells and the auditory nerve, resulting in increased spontaneous firing rates in the central auditory system. This explanation, however, falls short in explaining patients who develop tinnitus suddenly or experience fluctuating symptoms. To bridge this gap, Dr. Djalilian delved into patient histories to uncover common triggers and patterns.
His research revealed a connection between tinnitus and migraine-related triggers, such as stress, poor sleep, caffeine, and alcohol consumption. This insight led him to adopt migraine-based approaches for treating certain tinnitus cases, which have since become central to his practice. Despite these advancements, managing tinnitus remains a significant challenge, as existing therapies like masking hearing aids and retraining therapy offer limited relief. A deeper understanding of tinnitus mechanisms is needed to develop more effective treatments.
Dr. Djalilian also notes that many tinnitus patients experience symptoms as part of a migraine-related process, even without classic headache symptoms. Early clinical trials, which grouped all tinnitus patients together, often masked meaningful results. Now, current trials focus on specific subgroups, such as those with fluctuating or intermittent tinnitus, to improve treatment outcomes and identify effective therapies.
[Dr. Joe Walter Kutz]
What do you see as the newest thought on the pathophysiology of tinnitus?
[Dr. Hamid Djalilian]
Yes. Traditionally, pathophysiology of tinnitus has been explained as, well, you have loss of cells in the inner ear or the loss of the synapses between the hair cells and the auditory nerve. However, that can explain the fact that there is an increase in what's so-called spontaneous firing rate in the central auditory system. Now, when we actually think about this is you think about, well, what's happening in a person who, let's say, was 49 years old, had the same degree of hearing loss as they've had for the last couple of years. Then suddenly they turn 50, let's say, and then their tinnitus becomes either loud or becomes noticeable.
There must be something that's changed. This can't be something that's just the spontaneous firing rate just went from nothing to a whole lot in that span of time. The people who say, I have tinnitus that comes and goes. I have it some days and it's really bad. Then I have somebody that's completely quiet. If that spontaneous firing rate is there, it's probably not coming and going. Then you have this other category of patients who say that I've had this tinnitus for a long time. It was very quiet and I didn't notice it most of the time. It was not bothersome.
Then it just after this sudden event, usually I have some event they'll notice or something, it became very loud and it stayed loud. The traditional pathophysiology really doesn't explain that. Then what I try to do is, as we talked in that previous episode, when I have a problem that I can't figure out, I try to basically ask more and more questions of patients and try to figure out what makes it better and what makes it worse and to see if there's a common pattern in these things. As much as I probably at the initial onset, when I started my practice, I said, oh, I don't want to see patients with tinnitus because really I didn't have a solution for them.
Then I thought if I want to figure this out, I actually have to see patients and talk to them and figure out their stories and see if there's a common pattern. Over time, I was able to figure out that there is a common pattern of what triggers the tinnitus to become worse. That's sort of tied in with the migraine research that I was doing related to how it causes vertigo and whatnot.
I realized a lot of the triggers that people are talking about, stress, poor sleep, caffeine, wine, et cetera, those are the same ones that trigger regular migraine headache or a distributor migraine attack. That's what made me think, I wonder if there's a connection between tinnitus and migraine. Then we actually started treating the patients with these fluctuations of tinnitus or the ones that suddenly increased as migraine and that has evolved into what we're doing now.
[Dr. Joe Walter Kutz]
I have the same challenge. You'll see a patient with tinnitus and it's a very frustrating condition. I agree that the treatments are limited. We basically will have our audiologist be with them and try hearing aid, a masking hearing aid, some tinnitus retraining therapy, which can be helpful, but we do need better treatments. Do you think part of the challenge with the randomized control trials and the trials on tinnitus is that there's such a high placebo effect and the fluctuation in tinnitus? Why haven't we been able to find either a medication or supplement that has been shown to treat tinnitus on a randomized trial?
[Dr. Hamid Djalilian]
Yes, that's a great question. I think there is definitely a placebo effect. Part of it is because tinnitus gets worse with, as I said, this migraine-related process. These are people who don't necessarily get headaches. Some of them do, but a lot of them don't get headaches. The only manifestation of the migraine is this increase in the level of tinnitus. I think what we were doing before in a lot of trials is we're just packing all the same types of patients into the same trial. I've made that mistake myself.
Now that we have a much better understanding, our current trials, we are looking specifically for people with fluctuating tinnitus and the ones that change the levels or intermittent tinnitus. I think that's one of the challenges. You have a placebo effect. The second you have a heterogeneous population. I think that's been the main issue that we've had in our trials, in that if you have this heterogeneous population, even if let's say, I don't know, 40% of the patients have a significant benefit because the placebo effect is pretty high, you then actually will look like there was really no significant effect.
Then when we actually look at the individual group and say, hey, it looks like this group had a big benefit. What's characteristic about these patients that the other ones didn't have? Then I think we can sort of parse it out. I think supplements, as you bring up supplements, there's unfortunately a completely unregulated market. We have actually now figured out that there are a few supplements related to migraine that do have an effect. There is a lot of mixed supplements on the market, which look somewhat similar in terms of what they have in them.
We do use supplements, and I can get into it a little bit more, but not the traditional ones that you get that are mixed for tinnitus. These are just things that people will buy individually. Those are supplements that are involved with migraine. Some people who really have a deficiency in those with chronic migraine, which some of these people do, then they do get a benefit from them.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Migraine & Tinnitus Triggers
Identifying and addressing individual triggers is important for managing tinnitus effectively, particularly when it is associated with migraine-related processes. Sleep is one of the largest triggers for tinnitus episodes. Poor sleep quality, often linked to undiagnosed conditions like sleep apnea, can exacerbate tinnitus. Treating sleep issues, such as through lifestyle changes or sleep studies, is often a critical first step.
Stress is another significant trigger, with daily stressors frequently worsening symptoms. Dietary factors also play a central role, with dehydration, skipping meals, or consuming certain foods—such as caffeine, protein bars high in tyramine, alcohol, and MSG-laden (monosodium glutamate) prepackaged foods—contributing to flare-ups. The impact of these dietary triggers can depend on other factors, such as stress levels or poor sleep. Dr. Djalilian encourages patients to focus on foods they consume daily and to pay particular attention to what they ate in the six hours before their tinnitus worsened.
Hormonal changes and overstimulation are additional factors. For women, hormonal fluctuations can trigger tinnitus episodes, although treatment focuses on mitigating other triggers to lessen their impact. Overstimulation, such as exposure to loud noises, atmospheric pressure changes, intense exercise, or visual triggers like video games, can also worsen symptoms. Wearing earplugs in noisy environments and limiting exposure to known triggers is a simple start to mitigating these episodes.
Understanding and managing these triggers often involves a combination of lifestyle changes and, in some cases, medication. Dr. Djalilian also highlights the value of patient education, recommending resources like Heal Your Headache by Dr. David Buchholz and professional organizations like the Migraine and Otolaryngology Society, which provide valuable tools for both patients and practitioners. These approaches aim to empower patients to achieve a manageable level of tinnitus, improving their quality of life.
[Dr. Joe Walter Kutz]
Let's say you diagnose a patient with this fluctuating tinnitus, and then you determine, "Hey, I want to treat this as a migraine phenomenon. For the listeners, what is your algorithm and how do you treat them? What's your goal of treatment?
[Dr. Hamid Djalilian]
Sure. I usually will start naming off the triggers. The five primary triggers are stress, poor sleep. I usually pause at sleep and I say, "How was your sleep at night?" As you've probably experienced very frequently, people will say, "My sleep is terrible." Or if they're a little bit overweight or if I'm looking in their mouth and they have a crowded pharynx, I will ask them about snoring and then I'll actually get a sleep study on them oftentimes because it is very common that people have undiagnosed sleep apnea or the sleep apnea starts that triggers this migraine which then triggers the tinnitus to suddenly become loud and treating the sleep apnea will help. Sleep is a very critical component of this.
People who get daily symptoms have daily triggers. It's usually a major stressor or it's a daily sleep problem or it's a daily dietary item. We'll get through the other one. Stress, sleep. Next is diet. I tell them the diet has three components to it. Dehydration is a major trigger. I tell them they need to drink at least two liters of water. I ask them to eat on time, don't skip meals. I've had several patients whose tinnitus started with intermittent fasting or it got worse with intermittent fasting and just correcting that fixed the problem for them. The third is then the diet itself.
Now, as we were talking before because the heterogeneous population and whatnot, there are a lot of studies and the purists will say there are no studies that show caffeine makes migraine worse. There's no studies that show let's say chocolate or wine or whatever makes migraine worse. The reality is actually, not everyone's sensitive to every one of these food items. These food items are not sometimes individually a problem, but when combined with other things. For example, I tell patients if you're on vacation, you're relaxed, you're getting great sleep.
You can probably have wine and you're not going to get any symptoms but if your stress is high and your sleep's been poor and you drink the same wine, you're going to get over the threshold and you will get your symptoms. We have to tell them that while the diet's important, it is a multifactorial phenomenon. The diet is difficult to do. I definitely would admit to that myself as a migraine sufferer but I will tell you that what I generally do nowadays is I tell patients, I want you to focus on the foods that you eat on a daily basis first. Most commonly, those are caffeine and I do recommend complete elimination of caffeine, not even decaf coffee because that has caffeine in it.
Second is protein bars and protein shakes are very high in tyramine. They tend to be something people drink a lot or eat a lot on a daily basis. Then the third is wine that some people tend to drink on a daily basis or beer which is also high in tyramine. Then I tell them about fast food and pre-packaged ready-to-eat foods that are savory, that have MSG in them, those are sort of the ones I tell them to concentrate on. Then with the intermittent tinnitus or the fluctuating ones, I tell them to concentrate on the six hours before your tinnitus got loud to see what happened in that six hours that made your tinnitus louder and that's when I want you to drill down on the diet.
Then the next we talk about is hormonal changes. Hormonal changes mostly affect women, of course, but in men, I have seen it as with testosterone supplementation where actually stopping the testosterone supplement actually improve the tinnitus. Those are just some things that, in women, we can't do much about the hormone fluctuation but we try to fix everything else around it so that we can limit the impact of the hormonal changes. Then finally, it's overstimulation. Overstimulation, most commonly for tinnitus, what makes tinnitus loud is loud sounds.
A lot of people will say, I go to a loud restaurant and I go home, the tinnitus is blasting and then the next day it settles down. Or a lot of patients will associate it with atmospheric pressure changes. They say after an airplane flight, it gets loud or there was a thunderstorm or right before a thunderstorm, my tinnitus gets louder. Then I tell them about other things like very intense exercise, getting overheated.
Sometimes people are sensitive to light or motion. I've had patients who play video games and after playing the video games, their tinnitus gets louder. It's because of the visual overstimulation. I tell them just so that they're aware of it. I don't tell them to avoid noise and things like that. If they're going to go to a concert, I tell them wear earplugs, of course. If they're going to be in an environment where they have noticed that is going to potentially trigger them, then they need to limit their exposure, at least to shorter time periods.
[Dr. Joe Walter Kutz]
Yes, that's fantastic. I know that you have your clinic set up with a lot of handouts, you have algorithms, you work with APPs that are versed at this. You can really have a practice to really treat many patients. For those of us out there that may not have those resources, we just haven't put that together for migraine-associated conditions or tinnitus like we're talking about, what's some good resources that can be used to help us learn more about these triggers and maybe we can even suggest these to the patients?
[Dr. Hamid Djalilian]
Sure, there is an organization I've been a part of from the founding is called Migraine and Otolaryngology Society. This basically started by a group of otolaryngologists and some other specialties who are interested in the manifestations of migraine in otolaryngology. Also, the Association for Migraine Disorders also started by Rick Godley, who was intimately involved in the Migraine and Otolaryngology Society founding. There are a lot of good resources there, including some free CMEs on AMD, a website that people can do that can teach them some of this stuff. I should mention also that in addition, we do use medication, so it's not just lifestyle and dietary changes.
We do have to use medications in some people. There's a little bit of nuance to that. The AMD website has some resources for physicians as well. I actually, because we've had some success with this, we've had a lot of patients from out of state who have been contacting us who want to see me, but because of state licensing, I can't really see and prescribe medications across state borders. I've actually partnered with a telemedicine clinic that has people who have licenses in multiple states, and they've been actually implementing this treatment across the country now. If people are comfortable doing the lifestyle, dietary changes and stuff and the medications, great. If not, there are other resources out there for them too.
[Dr. Joe Walter Kutz]
On the patients that, well, getting back to that. I recommend patients read books like Heal Your Headache by Dr. Buchholz, and I've read through that book. I think it's very helpful just to give them something. If the right patient wants to read a lot about this instead of Dr. Google, we give them a good resource. Even me reading through that, and I had a patient that was having Pacific migraines. He's, I don't know, a 50-year-old gentleman, no problems before, and I asked him more detail about what had gone on, what he had changed, and he went on a low-carb diet, and he was eating a lot of nuts every day.
I said, "Well, that's a migraine trigger." I had no idea. He stopped that, and he was better within a few weeks. I think really familiarizing yourself with these triggers and really, it's an easy way to help a patient out. He changed his diet and that all improved. I think books like Heal Your Headache, these resources you discussed are important for us and the patients. Now you're treating patients, these patients with tinnitus, probably related to a migraine phenomenon. What percent of patients do you think improve enough that you're able to get their tinnitus down to a level where, "Hey, I still have the tinnitus, but I can live like this and I'm much happier?"
Other Atypical Migraine Symptoms
Diagnosing and treating patients with atypical or otologic migraines is challenging due to rigid diagnostic criteria. Traditional migraine criteria, such as having five headache episodes of a certain duration, often exclude patients who don’t meet every checkbox, leaving many undiagnosed and untreated. Dr. Djalilian emphasizes that these criteria, while useful for research standardization, are not definitive and should be applied flexibly in clinical practice.
Atypical migraines, particularly those without headache symptoms, are commonly overlooked. Many patients present with symptoms such as neck stiffness (often on the same side as tinnitus), sinus or ear pressure, sound sensitivity, or hyperacusis. These symptoms, while not aligning with classic migraine definitions, still represent forms of migraine rooted in central brain sensitivity. For example, conditions like ocular migraines, abdominal migraines, or cyclic vomiting in children lack headache symptoms but are recognized as migraine-related processes.
Migraine is not synonymous with headache but rather a condition of central sensitivity involving various nerves, such as the trigeminal nerve. Patients often recall a history of atypical migraines, such as ocular migraines, only after further discussion. This highlights the need for a broader perspective in diagnosing and treating migraines, especially in patients with atypical or non-headache manifestations.
[Dr. Joe Walter Kutz]
One thing when I send a patient to neurology thinking they may have some migraine, it could be a vestibular migraine or some other otologic symptom causing migraines, a lot of times you get pushback. They don't fit the vestibular migraine criteria exactly. It's a very detailed criteria and, oh, they don't qualify because they missed this one checkbox. I guess, just overall, do patients have to have a history of headache?
[Dr. Hamid Djalilian]
Yes. No, that's a great question. That's what's been the biggest obstacle for patients who have this so-called atypical migraine or otologic migraine, as we call it, in getting proper treatment is because everyone is so focused on the criteria and if they don't fill all the checkboxes of five episodes between this number of minutes and this many hours, et cetera, then it's not a migraine. The problem with that is that I usually tell people, those criteria were not written by God. These are written by people and people change their minds. It's just that it takes time.
From the time something is discovered until it's implemented by half the physicians is 17 years. It takes time for people to catch on and say, "Okay, well, maybe there is actually evidence that there is something other than just these criteria." Now, I think the criteria are important if someone is doing a study on, let's say, migraine headaches, you need to have strict criteria.
If you're looking at this sort of atypical form of migraine and how it affects the ear and things like tinnitus and dizziness, et cetera, then we need to be a little bit more flexible because when we look at these patients, we have actually done studies on multiple groups of patients with various conditions to look at whether they fulfill the criteria and how short of the criteria were they. When we look at this, about maybe half the people fulfilled the migraine criteria and then another maybe 15 to 20 some percent will fulfill four headaches and not five.
Then there's a few, maybe about another 20-some percent, that's like they fulfilled three out of the five criteria. Then a very small percentage left that actually doesn't fulfill any of the criteria. Most of the patients have these criteria. If you think about, if I've had four migraine headaches in my life, I technically can't be diagnosed with a migraine diagnosis when in fact, what's to say that one, it wasn't migraine? Because how did I get the first one? It just depends on where you're catching people. You catch people towards the end of the life, maybe you'll get all five of them.
Unless someone has a very recurrent basis, you won't see it. A lot of people, especially men, we see have atypical symptoms. These atypical symptoms most commonly are stiffness of the neck muscles, which we've often found to be on the same side as the tinnitus and/or sinus pressure, ear pressure, sometimes just sound sensitivity or hyperacusis. A lot of hyperacusis is related to migraine as well. These patients oftentimes have these atypical symptoms and say, "Well, I don't get headaches. I just get this head pressure or I just get this neck stiffness. That's not a migraine."
I try to explain to them, "Well, no, this actually is a migraine. It's just a different form of it." It's so common that my resident will go see the patient and they'll come out and they say, "Well, they have no history of migraine." Then I go in and as soon as I go in there, they say, "Oh, you know what? I used to get ocular migraine when I was younger. When I think about it, they remember that, "Oh yes, I used to get these atypical forms of migraine." When you think about atypical migraine, ocular migraine is not a form of migraine.
It doesn't have headaches. Abdominal migraine, which is usually sometimes in children, so the cyclic vomiting or in adults in the form of IBS and stuff, those don't have headaches associated with them necessarily. You can get other forms of migraine that do not have headaches. Migraine is not synonymous with headache. Migraine is a central sensitivity. It's basically a brain sensitivity condition that causes various symptoms depending on what is all involved. It's a lot of times through the trigeminal nerve, but it could be through other nerves. As I said, you could get abdominal symptoms. That's not the trigeminal nerve, but it's all directed by the brain.
Podcast Contributors
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). (2024, October 8). Ep. 194 – Tinnitus & Migraine: Expert Insight [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com 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.
Podcasts
Articles
New Treatment Options for Tinnitus: Lifestyle, Supplements & Medical Devices
Treating Otologic Conditions as Otologic Migraines