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BackTable / ENT / Podcast / Transcript #60
Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Otologic Symptoms Indicative of Migraines
(2) Treating Meniere's Disease
(3) Prescribing Nortriptyline: Dosage, Side Effects, & Other Concerns
(4) Prescribing Topiramate: Dosage, Side Effects, & Other Concerns
(5) Addressing Sudden Sensory Hearing Loss
(6) Treating Vestibular Migraines
(7) Alternative Recommendations for Migraines
(8) Working with Physician’s Assistants and Nurse Practitioners
(9) Persistent Postural-Perceptual Dizziness
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[Gopi Shah MD]
Hello, everyone. Welcome to the back table ENT podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice.
[Walter Kutz MD]
My name is Walter Kutz. I'm a professor of otolaryngology and neurological surgery at the University of Texas Southwestern Medical center. And I'm here today to discuss otology and migraines with Dr. Hamid Djalilian. Dr. Djalilian is a professor in otolaryngology and biomedical engineering at the University of California Irvine School of Medicine. He received his medical degree with honors from the University of Minnesota, and completed his otolaryngology residency at the same institution. He completed his fellowship training at Minnesota Ear, Head and Neck Clinic at the University of Minnesota. Dr. Djalilian has published over 150 peer reviewed manuscripts. He is an innovator who has developed treatments outside the mainstream traditional approaches. In particular, Dr. Djalilian believes in a relationship between migraines and many otologic symptoms, including Meniere's disease, vertigo, hyperacusis, mal de debarquement and otology, as well as other symptoms, Dr. Djalilian, welcome to the BackTable ENT podcast.
[Hamid Djalilian MD]
Thank you. Thanks for the invitation.
[Walter Kutz MD]
Great. Could you tell us a little about your weekly practice, kind of what your week looks like?
[Hamid Djalilian MD]
Sure. So I see patients two days a week. I do surgeries, two days a week. And then, I do research the rest of the time.
[Walter Kutz MD]
Excellent. So, and how many patients do you see a day in your clinic?
[Hamid Djalilian MD]
I generally have about 50 patients between me and my physician assistant who helps me. And I usually have a resident who helps me as well, but I probably end up seeing about maybe 40 of them, myself with the PA and the resident. And then some of them are usually some things that the physician assistant sees on our own.
(1) Otologic Symptoms Indicative of Migraines
[Walter Kutz MD]
Excellent. Yeah, that's a busy clinic, certainly. So I'm going to jump right to it. 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.
[Walter Kutz MD]
Interestingly. So, you feel that you say all patients with Meniere’s disease have some sort of migraine variant or to associate with migraines. So what is your treatment approach for Meniere's disease? I think, typically I would start with a low salt diet, maybe put them on a diuretic. If that doesn't work, consider betahistine. What is your initial approach for a patient with Meniere’s disease?
(2) Treating Meniere's Disease
[Hamid Djalilian MD]
Yeah. 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 neurotoxic. 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. I think one thing we have to get comfortable with, if we're going to treat patients with migraines is the medications. And that's really not in our training or at least not in my training back in my residency and fellowship. So I think nortriptyline, it sounds like it's a good first line. I think it sounds like most otolaryngologists can get pretty comfortable treating that. Can you tell me a little bit about your dosage and side effects and concerns with nortriptyline and how you discuss this with a patient?
(3) Prescribing Nortriptyline: Dosage, Side Effects, & Other Concerns
[Hamid Djalilian MD]
Sure. So I start with, usually depending on the patient, if someone is getting very frequent vertigo, and just wants to get better, like ASAP, I will start them at 25 milligrams. And then usually go for two weeks and then increase it to 50. And then if they're not better after two weeks of that, then we'll go to 75. But most patients, we're not getting very frequent vertigo. I will start them at 10 milligrams and then every two weeks will increase by 10. So we go 10, 20, 30, and then from 30, we'll usually jump to 50 and then 75, that's sort of the routine.
The main side effects, I tell the patients, usually, don't panic when you see the side effect list on the package, insert that the pharmacy will give you. I sometimes tell them, don't look it up, because nortriptyline was FDA approved for depression at very high doses. We never reach those doses that nortriptyline was used for. So we rarely see those uncommon side effects that are listed on the package insert. The side effects that we do see is somnolence. So most people will get sleepy from it. And I think that's one of the potential reasons nortriptyline, in addition to probably its anti-migraine activity, it helps because it makes people sleep better and sleep is a very significant trigger for patients with migraine. The second is at low doses and nortriptyline has an anti-anxiety effect. And so it does help with the stress component of migraine, which is another significant trigger. Stress and sleep are probably the most common triggers. So it sort of controls two of the triggers in a way, plus it helps them with the migraine at the same time. And then, I tell them about somnolence. I tell them about dry mouth. Some people get dry mouth at low doses, but generally speaking, it's not a big problem, I must say. People can get tachycardia from it. I tell them to check their heart rates before they go up on the dose, make sure that it's less than a hundred, their heart rate. If we're going to maintain them at 75 or raise the dose potentially, sometimes people have gotten better, but they're not fully better. So they're at 75. And so then I want to push it up to like 85 or maybe a hundred sometimes. I will then get an EKG to check for the QT interval or the QTC technically, and to make sure that that's not increased, because rarely of course, nortriptyline is associated with increased QTC interval. And so we just have to keep that in mind if we're going to keep them on it long-term. I don't check blood levels like was traditionally done in psychiatry. I just go based on the EKG.
[Walter Kutz MD]
One of the challenges of nortriptyline is if I have a patient, either with vestibular migraines or Meniere’s disease I want to treat as a migraine variant, they may be on other medications, psychiatric medications, other migraine medications, or maybe it's a patient that's an older patient. I worry about putting these patients on these sort of medications, you know, again, being an otolaryngologist, not a neurologist. How do you address the patients that are on medications for migraines or maybe psychiatric medications, anxiolytics. And also, secondly, are you comfortable prescribing nortriptyline for older patients?
[Hamid Djalilian MD]
Yeah, great question. So I usually will do nortriptyline if there, I used to actually not do it at all, if they're on another serotonin blocker of some kind, an SSRI or SNRI. Over time I have become a little more brave, I should say. As long as they're not on like four times the dose, I had a patient, who is a psychiatrist himself. He was on like two or three antidepressants and he had sudden hearing loss and I treat sudden hearing loss as a migraine phenomenon. And so I give them nortriptyline and I told them, serotonin syndrome. He said, we never worry about serotonin syndrome. I said, well, just keep track of your heart rate and all that. And, I tell patients if they're on it, other antidepressants at high doses, usually four times the starting dose. So for example, for Zoloft, if they're on 200 milligrams or something, I'll tell them, if your heart rate goes up, you feel the sweating and things like that go to the ER and say, I'm on these medicines and they will know what to do. So that's what I usually tell them. I must say I haven't had any, I do give it to elderly patients.
Some patients are very sensitive, so migraine patients are very sensitive to medications. So sometimes I will start them using the liquid nortriptyline, which is for pediatric usage. So I'll give them like five milligrams or sometimes even two milligrams. And so I have given it in elderly. There is a warning that comes up on the electronic record system about over 65 and the problems with anticholinergics and things like that. I must say I have not had that problem. People generally start feeling well at some point, it's uncommon in the elderly. We have to go up really high on the dosage. I do use paroxetine or Paxil as an alternative to nortriptyline if there's any question of arrhythmia. So if the patient has an arrhythmia history, I don't want to risk it. So I will not use nortriptyline in those cases, I'll use paroxetine or topiramate. So topiramate is a very good medicine or Topamax. If someone has an extensive cardiac history and you're worried about messing up their blood pressure or heart rate or rhythm then topiramate is something that's totally foolproof for that kind of problem.
(4) Prescribing Topiramate: Dosage, Side Effects, & Other Concerns
[Walter Kutz MD]
Yeah. Actually, I'm going to ask you about topiramate. I know that's a second line treatment. What are the side effects of topiramate that you're concerned about? It sounds like you feel it’s very safe medication for most patients, but what kind of side effects do you discuss with patients?
[Hamid Djalilian MD]
The main side effect that people can get from topiramate at the low dose, I should say at low doses, it’s very uncommon that people get side effects, but if they do get side effects, it will be sometimes they'll get paresthesias around their lips or their hands, their fingers. It is a carbonic anhydrase inhibitor so it sort of has that effect, like acetazolamide does, and then very uncommonly patients can have kidney stones from it, because it acidifies the urine. So I tell them that if they have kidney stone history, then I don't give it. Or sometimes I'll say, if that's the only thing left, I'll tell them, go check with your urologist to make sure you can take this because there are some stones. If their stone has been identified, acidification is not an issue for it.
[Walter Kutz MD]
What's your typical dose regimen for topiramate?
[Hamid Djalilian MD]
Yeah, topiramate I start it at 25, and go up once a week, by 25 milligrams, up to 150. So it's a six-week regimen. Most of the dosage regimens I have are six week regimens. So I start the patient. It's not too long so that they don't feel like I'm abandoning them by telling them to come back three months later. And then at the same time, I want to be able to have control over it, so that if anything is not working, then we can make adjustments quickly for them so that they don't suffer for too long. So I usually will start them on whatever medicine we're going to start, and see them usually in six weeks. And then, based on what their symptoms are at that point, then we'll make changes to their regimen.
[Walter Kutz MD]
I think we've spoken about this before, if nortriptyline is not working a lot of times, you'll add topiramate to that. Is that true?
[Hamid Djalilian MD]
Exactly. Yeah. So, there is an additive effect that we see with the medications. So I will combine them, once they are better, then I'll slowly take away the first drug that didn't work as well. And then I generally try to, I tell the patients, this is for three months, you're going to be three months of stable symptoms, meaning no symptoms, or if you have a symptom you can easily identify the trigger. So they say, well, I didn't get good sleep this night, and then I got dizzy the next morning. And so then I know, well, it's a sleep problem. I'm not going to raise their dose or keep them on medication forever because they know what their trigger is. They just need to fix that problem basically. So I will usually keep them for three months on the combo. We'll start taking away the first drug and then we'll then take away the second drug. And then at the end, we'll tell them to start experimenting with the food items so they can find which food items they're triggered by. And then if everything goes well, they've identified their triggers, they can avoid them. And then there'll be good. I mean, I tell them, I have migraines, I know what my triggers are. I'm very careful with them. And so then I don't get symptoms. I don't have to be on daily medication. I don't have to do anything. I just know what I need to do to make sure I don't get it. And so then I'm very careful and that's what you need to do. That's what I tell the patients.
[Walter Kutz MD]
So, how do you tell them to log their symptoms? Is this something that you just leave it up to them? Are there suggestions like an app or do you tell them to journal? How do you tell them to log their symptoms?
[Hamid Djalilian MD]
Yeah. I have this little form that we created basically has like what their symptoms warrant, what time that was, what they ate that day. I usually tell them the trigger is generally within about six to eight hours of the episode. So I tell them if it's like three in the afternoon, look very specifically at what you ate at lunch, and how much water you had to drink and whether you ate enough and you're not hungry, whether you had stress. I usually tell them that if their sleep is inadequate or the sleep trigger, most commonly, they're going to wake up with the symptoms. So patients who wake up in the morning, it's usually most commonly going to be sleep, but it can be due to a food item they ate at dinner, for example, dehydration or hunger and not eating enough at dinner. And then, very critical early morning one is caffeine withdrawal. So I tell patients to completely eliminate caffeine slowly over a couple of weeks because caffeine withdrawal is a significant trigger for migraine.
[Walter Kutz MD]
I mean, you lost me on that one. I don't think I could do that.
[Hamid Djalilian MD]
Yeah. So I tell patients, I said, listen, I know this is going to sound strange to you, but I said, you will have more energy after you stop caffeine. And I'd read this before and I must say, I didn't believe in myself until I stopped caffeine myself. And a lot of the energy you get from caffeine is actually related to the withdrawal of the previous caffeine from your system. So if you actually are not drinking caffeine, you don't feel tired and therefore you don't get as much energy out of caffeine. Anyways, so I think you can try it. I think you might see.
[Walter Kutz MD]
Those side effects may be worse than any medicines we're talking about if I try to quit caffeine. It was interesting. You're mentioning that you treat sudden sensory hearing loss as a migraine phenomenon. Can you tell me a little more about that?
(5) Addressing Sudden Sensory Hearing Loss
[Hamid Djalilian MD]
Yes. 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.
[Walter Kutz MD]
That's very interesting. And, I do commend you, you have theories, but you also publish and you show a benefit of these theories and that I think it's very helpful. And I encourage all of the listeners to look at Dr. Djalilian's work on these subjects. Let’s move on. So I guess, vestibular migraines, do you treat these very similar to Meniere's disease? Are there differences in your treatment?
(6) Treating Vestibular Migraines
[Hamid Djalilian MD]
No, I treat them exactly the same way. I mean, I think that I am a little more aggressive on Meniere's disease. If they have a hearing loss that's more acute. or, and I should say that, a few years ago, I started treating even patients with chronic, sudden loss. So many that had a sudden loss three months or six months before. But they still had active migraine symptoms. I should say initially I treated everyone, but then now I'm a little bit more selective. But, what we found is that if somebody had had a sudden loss and we looked at a population of, I think, 20, 25 patients and we have the paper out there. And most of these papers are available because University of California, sort of wants all the papers to be available. So the entire paper is usually available to people on PubMed. And if not, people can not contact me, I'll send them the paper. But anyways, we looked at patients, who'd had a period of time after their sudden loss and we started treating them with just migraine treatment. And we found that about one third of the patients went from a non serviceable hearing, so hearing that couldn't be rehabilitated with a hearing aid, to serviceable hearing. And about 50% of them had some improvement and about 14% had a complete resolution of their hearing. They went back to their baseline.
And these were patients who had had months of hearing loss. I mean, I've had patients who had been down for three months or six months, and then we were able to bring their hearing back up and they could use a hearing aid or those few patients come back to normal. And what we found is that patients who had active migraine symptoms, so they had aural pressure, so pressure in their ear, or neck stiffness or a headache that was sort of continuous. I tell the patients there are two components to this. There is a reversible component to your hearing loss that might be due to an active migraine. There is an irreversible component to your hearing loss, which we can't control. And we don't know how much is which. So if you want, we can kind of go all in. Usually I just start with nortriptyline and topiramate, all the migraine regimen and the two supplements for six weeks. If they don't have improvement, then I will do intratympanic steroid injections. Or if there's some improvement they're not back to baseline, I'll do intratympanic injections, usually do two of them. If they've never been treated with prednisone for their sudden loss, I will put them on a course of prednisone as well. And so that's sort of the way I usually treat the chronic sudden loss. So if a patient with Meniere's comes in and they have a hearing that's been down for somewhere in the six month or less vicinity, and they have any kind of active pressure symptoms, then I will treat them aggressively right away with the migraine regimen, with the medications and everything.
[Walter Kutz MD]
So that's interesting. You will do steroid injections. I think most of us sort of put on an arbitrary six week, post event, sudden hearing loss. We maybe wouldn’t consider steroid injections. Although I agree with you, if somebody has what looks like hydrops, I've seen that respond even months out, but you'll even with what we think of as a viral or maybe I guess migraine sudden hearing loss you'll treat them with steroids even months out?
[Hamid Djalilian MD]
Yes. I discuss it with the patients. I tell them if they don't respond to the migraine meds, the chance that the steroid injections are gonna not work is high. But I said, we've had patients who've had improvement. So if you want everything done, then that's what we'll do. But we can be totally conservative. And I really don't try to push the injection because if the migraine meds have not worked, the efficacy is not very high. But I tell them there’s about a 10% chance that they will have some improvement with it, but, if they want it, I'll do it. If they don't, I definitely don't push it at all because, obviously there's a tiny risk. I mean the risk of perforation is very small. I mean, if we're very judicious with the phenol. And then the other issue is really that the cost of copays and stuff like that, that sometimes are an issue for some patients.
[Walter Kutz MD]
Yeah, very, very interesting approach. Before we leave that topic, do you recommend books? Do you recommend dietary supplementation? What other, besides the medications, what else do you tell the patients to, maybe some homework they need to do, books they need to read. You've kind of touched on this a little bit, but what else do you discuss with the patients?
(7) Alternative Recommendations for Migraines
[Hamid Djalilian MD]
Sure. So, just sort of for the listeners, I lay out the five main triggers, which are stress, sleep, diet, and I tell them the diet is dehydration, hunger, and then the food items. And the food items are primarily caffeine, glutamate, which is in preservative, so ready to be packaged foods, basically, things like that, tyramine, which is in protein that's been processed in any way, or protein that sits around a long time basically. It could be dried fruit. It could be a very soft fruit, things like that. Bananas are very high in tyramine. The fourth molecule would be histamine and that's in citrus fruits and in nuts. So I tell them about those. I have a handout that was actually originally developed by John Carey and Michael Teixido, and I made a lot of edits to it. I've changed the diet a little bit, based on sort of my own experience in reading, and added a number of other conditions. And I tried to make it a little bit more understandable for the patients. So I give them that handout. If there are patients who really want to drill down, I do have this like, it's like a grocery list, that I initially got online. And then I made a lot of changes to it. And then I will recommend they read the Heal Your Headache book, by the author, his name is Buchholz. And that has a very comprehensive diet chapter. And so I tell them to follow everything that's in that book.
[Walter Kutz MD]
One of the challenges I've run into is you may recommend reading a book and reading these handouts and it may be a patient that you just sense is not going to really do the sleep hygiene, dietary changes. And as a patient, I'm probably guilty of this as well. But, is there anything you do, if you have a patient, they come in and they say, no, doc, I just want you to give me medicine to get better. What do you say to them?
[Hamid Djalilian MD]
I usually tell them there are two parts of this deal. There is the part that I'm going to do, and there is a more important part that you have to do. And I say, if you don't fix your trigger, there’s no amount of medicine that can overcome some of these triggers. So if someone is consuming six, seven caffeinated beverages a day. If someone has obstructive sleep apnea, if they have chronic insomnia, I tell them we have to fix that as part of fixing this. I basically described to them that there's a threshold in the brain and when the brain activity reaches the threshold, then they will start getting symptoms. And, there are two approaches to this, one is to elevate the threshold so that they don't get symptoms. And that would be with medications. And the other would be to reduce the activity, which would be the trigger control. And I say, you have to do two together because the patients want the easy way out. And that's totally understandable. That's what I would want to do potentially, but I tell them this is a more natural way of doing it. You have to live with this condition forever. You might as well identify what's causing the problem and control that. Because especially in younger patients, I tell them, I'm not going to put you on medication forever. You need to learn what your triggers are, so you can manage this problem. So I really do try to spend time.
Now, I definitely agree that not every patient is compliant and definitely the average migraine patient has obviously more anxiety and stuff because that's a significant trigger for a lot of them. And so, they're not always easy to convince, but, I usually, when I see them sometimes initially, or, most times initially I see them with my PA or I see them on my own, and then they will follow up with my PA or nurse practitioner and then they will see them, and if they're not getting better than those sort of come back in and I’ll talk to them. And by the end I usually go and kind of lay down the law. I said, listen, you need to follow this stuff. Otherwise we're not going to even give you medications anymore because if you're not controlling that, we can't control the condition and then you're going to blame me, but it's really a problem that you need to be working on. And so I do have patients, if they're not getting better and they say, none of this stuff, you gave me work. And so I tell them, you're going to have to write down everything you ate, how much water you drank, how much sleep you got, all that stuff and bring that to me. And so then we can identify stuff for them because a lot of times, I've had a patient who was an engineer and he had this giant Excel sheet he brought in and he said, there is no pattern to any of this. And I said, just let me look at it. And it was very clear to me, every morning that he had a ham and eggs breakfast, he got dizzy that same day. But it was like six hours later, of course. And so, because the patients are looking for something that happens immediately, and I said, this is your pattern. And that's all he had to do. We fixed that problem altering his diet. There was no medication needed. So a lot of times it takes a little time. I've educated a few PAs and NPs, who work with me, who really spend the time because the patients do need a lot of time sometimes. And I just don't have the time to do this with everyone. And so I need to rely on physician extenders to help me, so that we can help more people.
[Walter Kutz MD]
Yeah, that was my next topic. And you discussed that. You’re seeing 50 patients a day. And one of the things as an otologist, we're surgeons, and I think we all enjoy being in the operating room and we also feel it's important to help patients with medical otology type problems. How do you work with your PA to make it efficient, to give these patients enough time to understand their treatment? Which is going to take time to understand that. Are there any tricks on training the PAs, do you do handouts, do you have sort of pathways? How do you create that system that you have?
(8) Working with Physician’s Assistants and Nurse Practitioners
[Hamid Djalilian MD]
I think one thing that is probably necessary is that if we're going to train the PAs, we need to sort of be comfortable with the medications ourselves. So I think that's sort of where it started. I used to just not have the capacity to see all these patients, so I would just start them on medication and I would tell him to send me emails through our email system. And then what I realized is that if one is not as hands-on with the patients, it's sometimes hard to fix this. And so I, there are very few sort of medical otologists out there. And so I thought that probably the best way to treat these patients would be to have a physician extender who can do this. And so they usually will come and spend a couple of weeks, initially it might be three to four weeks, with me. The volume of these patients is so high that they kind of learn the drill. I mean, I had a high school student who volunteered and wanted to learn about medicine and she spent a month with me. And then at the end she sent me a thank you card said, thank you for everything. And then, I can now diagnose and treat all migraine related ear disorders, because she had just seen so much of it. And so I think the PAs and NPs learn really quickly.
And, I've been incredibly impressed with how intelligent the NPs and PAs that I've worked with have been, and how quickly they pick it up. I do have them read the Heal Your Headache book. I do give them the handout. I do give him a couple of talks on migraine, the medication, and treatment. And then, on some of the other stuff like BPV management, and then sudden hearing loss and how to do the injections. And, I have them come into the OR with me because I usually do my intratympanic steroid injections, like in cochlear implants before we start. So the steroid can be in there longer. And so they will come in and do that with those patients and learn, where I could sort of coach them better. Then they started doing it in clinic with me. So then they can independently manage all these patients. So if they need steroid injections and whatever, they can do all of that stuff. And so then the PA will see patients on other days where I'm operating or I'm doing my research. And so then they can, essentially, take care of all the patients. So then the only patients that will sort of then come back to me are the ones who are not getting better after a couple of medicines. And we're trying to figure out why they're not better. And then I'll sit and spend a little more time with the patient to try to figure it out.
[Walter Kutz MD]
Yeah, we have excellent PAs as well. They treat these patients, they’re very helpful. It's interesting you have the PAs and your nurse practitioners do the steroid injection. That's something we have not utilized, but that probably works very well, especially if somebody's in trouble and you're out of the clinic for a few days. Have there been any issues with your university on having the PAs perform the injections?
[Hamid Djalilian MD]
No. Basically, the way that our sort of privileging works, is that they have to have done three under supervision. I have to have given him a lecture, there has to be a quiz on the lecture, and then, sort of grade the quiz. And then, we submit it, and it allows them to have the privileges to do it. It's not a very difficult procedure. I think in terms of injection, I think a lot of it is they get comfortable with using a microscope and cleaning cerumen. Injection is sort of really the next sort of thing that they got to do. I've not had thankfully, any problems with perforations or any issues at all. I tell them about all of the nuances that I've learned to prevent perforations and side effects like dizziness and things like that from the injection. And they're really good about sort of following the regimen. And so I haven't had any issues. I mean, obviously those issues can occur from me doing them or my residents doing them. Probably in the last, I think, four or five years I have had an NP or a PA or both. I haven't had any problems with that at all, and our institution has been okay. They just wanted a regimented system of a lecture, a quiz, and hands-on training. So we've done all that to prevent any complications.
(9) Persistent Postural-Perceptual Dizziness
[Walter Kutz MD]
No, that's great. Very helpful. I'm going to pivot a little bit. 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, 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.
[Walter Kutz MD]
Well Dr. Djalilian I think that sums up the talk and I really appreciate your time. I want to be respectful of your time. Are there any other comments you may have, that I may have not have asked that you'd like to tell the audience?
[Hamid Djalilian MD]
I would make good friends with your sleep colleagues. If someone has sleep apnea, I will send them to my colleague in our department who's a sleep specialist. If they have insomnia, we usually send them to our psychiatry sleep specialists, because sleep is a significant component of migraine in a lot of patients. And I think that's something that we need to look at on every patient. So I do ask everyone about snoring and sleep apnea. I look at their oral pharynx, look for signs of potential sleep. And so I do get sleep specialists involved very early. And sometimes for sleep apnea patients, I tell them, I'm not going to treat you until you get your sleep apnea treated because some patients just fixing their sleep apnea will fix the entire problem. So, that is probably one thing.
I would really encourage listeners to tell patients, and hopefully they recognize this stuff, to give them confidence that they will get better. Because I think that's sort of a significant component of the stress that sometimes people have is the fact that they have this condition they've had it for months and it's not getting better. And so if they have hope, and you do all the right things, then you can help a lot of patients. And, you will find, I think, that those are the happiest patients we have. And I think they have a lot more happy patients, who have had migraine related issues than the patients who get the surgery they're happy and then they kind of move on and you don't see them back anymore. But the migraine patients they're happy and they will do everything possible to help you for other things. And I mean, we've been very fortunate to have had a lot of patients who've donated to our research, which has allowed us to do a lot more work in research by bringing in more people to not only study the clinical aspect, but also the basic science aspect of this. And so I think that's a critical component in really helping the patients. And you will have a lot of happy patients from that.
[Walter Kutz MD]
Well, Hamid, thank you so much for your time. This was just a great discussion. I think listeners are going to learn a lot from this, and I've certainly enjoyed reading your work, talking about your treatment style, and it has changed the way I've treated these patients. And I do agree with you, when you're successful with these patients who have these chronic debilitating conditions, they are your most grateful patients. So continue the good work. And I appreciate your time today. And I hope the listeners learn as much as I did.
[Hamid Djalilian MD]
Thank you very much for the very kind invitation. If listeners have any questions, feel free to contact me directly, as well. Nothing gives me more pleasure than teaching other physicians to do this because it basically allows us to help more patients across the world really. It's probably the most common thing I talk about. And even though I would rather talk about surgery, and all that, but I think I can help more people sometimes talking about migraine, because it's a very underserved population, because very few people understand this condition, unfortunately. And, fortunately more and more people are understanding it and are helping patients. So, thank you for the invite and allowing us to get the word out.
[Walter Kutz MD]
You're welcome and thank you for being here. And I think we'll wrap it up.
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). (2022, May 24). Ep. 60 – Otologic Manifestations of Migraine [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.
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