HSC Section 8_April 2017

H. M. WEINREICH AND J. P. CAREY

TABLE 1.

Antimigraine medications and doses

individuals. Large population studies show patients with greater than 20% over ideal weight are at risk for BIH (10). Weight loss is one of the initial treatments of BIH. Our patients generally report losing weight while on a migraine diet. It is possible that patients had underlying BIH and loss weight, thus leading to resolution of their PT. This is unlikely as many had negative imaging. Unfortunately, though, we were not able to assess weight loss as these data were missing. The addition of migraine into a PT differential could potentially alter the work-up. However, the authors do not advocate treating migraine and abandoning diagnos- tic testing to rule out more serious causes. A complete head and neck examination should be performed includ- ing palpation and auscultation of the periauricular region, orbita, neck, and chest. A history and examination that includes: objective tinnitus, PT that can be altered with pressure on the neck, blurred vision, papilledema, syn- cope with head position or headaches not meeting criteria for migraine cannot be ignored and warrant further work-up. In our study, 12 out of 14 patients reported headache improvement while on a migraine diet. Numerous studies have supported the theory of food as a migraine trigger and an elimination diet as treatment. Finocchi and Sivori (11) suggest a non-IgE antibody-mediated mechanism in food allergy that may play a role in migraine. The study is a retrospective review to formulate a hypothesis and determine if this warrants further exploration. Given small numbers, inconsistent data collection, and variability in definitions, minimal stat- istics were performed. We relied on ICD-9 coding to determine diagnosis of migraine and tinnitus. Failure to assign these as a visit diagnoses means individuals were missed. Second, no consistent definitions were applied although usage of one surgeon’s experience minimized variability. Moreover, there is no ICD-9 PT code and a PT categorization required a description in the chart. The lower prevalence of tinnitus is a reflection of the senior author’s practice and referral pattern whereby vertigo is more commonly observed than tinnitus. If the primary chief complaint was not tinnitus, it may not have been listed as a visit diagnosis and therefore, patients with tinnitus were missed. Some of this data was captured on paper questionnaires. However, with a tran- sition to an EMR, the paper records were not available for every patient and the data were incomplete.

Medication

Dose

Amitriptyline

15 mg q day 120 mg q day

Diltiazem

Nortriptyline Topiramate Venlafaxine

10–30 mg q day 50–150 mg q day

75 mg q day

lists medications and dosing. Duration of medication treatment could not be calculated. Fifteen of the 16 patients reported history of headache and/or vertigo in addition to PT. Specifically looking at treatment among patients with headache, most patients found improvement in headaches as well as PT (Table 2). One patient did not try the diet, did not start a medication, and had no improvement in headache or PT. The PT prevalence among migrainers was 1.9% in a tertiary neurotology practice with 11 out of 16 patients reporting PT improvement with migraine treatment. This is the first study to examine the PT prevalence among migrainers. The pathophysiology for this is not clear. Possibilities include pulsations of the brain, cortical depression, or vascular changes transmitted to the coch- lea or perceived by the brain. This idea is supported given 14 patients experienced headache with their PT and 12 had resolution of one or both symptoms. An interesting example is a patient with known SCD who elected not to undergo repair. He presented with PT, sinus congestion, autophony, and vertigo triggered by straining. oVEMPs and imaging were consistent with SCD. Before undergoing SCD repair, he was treated for migraine and reported resol- ution of headaches, vertigo, and PT. Obesity could be a confounding factor. The odds of chronic headaches are 26 to 34% higher among over- weight individuals (7). Ohayon (8) found adults with BMIs > 27 were more likely to report headaches than adults with BMIs 20 to 25. The relationship between conditions known for PT and obesity is well known. Benign intracranial hypertension (BIH) prevalence is two per 100,000 (9) with a higher incidence among obese DISCUSSION

TABLE 2.

Symptom improvement among patients with headache

Symptom Improved

Migraine Treatment

Pulsatile Tinnitus Only

Headache Only

Both Better

Neither Better

Total

Diet only

0 0 0 0

2 1 0 3

5 4 0 9

0 1 1 2

8 6 1

Diet þ medication Did not try diet

All patients

14

Two patients excluded as they did not have headache.

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