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Prevalence of Pulsatile Tinnitus Among Patients With Migraine
Heather M. Weinreich and John P. Carey
Division of Otology, Neurotology and Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, The Johns
Hopkins University School of Medicine, Baltimore, Maryland
Objective: To examine the prevalence of pulsatile tinnitus
(PT) among patients with a diagnosis of migraine and to
determine if treatment of migraine improves symptoms.
Study Design: Single-institution retrospective patient review.
Setting: Academic tertiary referral center.
Patients: Billing data capturing ICD-9 codes and
388.3x was used to identify patients with history of migraine
and tinnitus. Patients were excluded if the symptom of PT
could be attributed to an alternate diagnosis. Data were
extracted from the patients’ electronic medical records.
Intervention(s): Therapeutic patients were prescribed a strict
migraine diet with or without migraine medication.
Main Outcome Measure(s): Subjective improvement in
tinnitus as documented in electronic medical records.
Results: One thousand two hundred four patients were
identified with an ICD-9 code for migraine and of those
patients, 12% (n ¼ 145) had an ICD-9 code for tinnitus. After
ruling out alternative causes, the prevalence of PT among all
patients with migraine was 1.9%. Of migrainers with PT
who underwent migraine treatment, 11 out of 16 reported
resolution or improvement of their PT.
Conclusion: PT can be observed in the context of migraine.
Migraine treatment with avoidance of dietary triggers with
or without medication can possibly lead to resolution of
PT. Key Words: Diet— Headache— Migraine— Pulsatile
tinnitus.
Otol Neurotol 37:244–247, 2016.
Pulsatile tinnitus (PT) is the perception of a pulsing or
rhythmic sound. The differential is broad and includes
vascular, nonvascular, and serious pathology such as
dural arteriovenous fistulas. An aggressive workup
should be performed given the risk of missing a serious
diagnosis. The dilemma occurs when no middle ear mass
or audible bruit is found. Even after extensive imaging,
no diagnosis is found in one-third of patients (1). We
propose migraine as a possible cause.
Migraine is one of the most common conditions in the
United States (2). Approximately one-fifth of the popu-
lation reports migraine with the highest prevalence
among women (3). Abnormal electrical activity and then
depression in or around the brain leading to vascular
changes is observed during migraine (4). One theory is
central neuronal hyperexcitability involving overactivity
of excitatory neurotransmitters (5). Nitric oxide affects
the trigeminal system leading to increased calcitonin
gene-related peptide release and downstream effects of
vasodilation and nociceptive transmission (6). Is it
possible this vasodilation not only leads to the sensation
of a throbbing headache but also the perception of
throbbing either by a central process or by vasodilation
of vessels around the cochlea leading to PT?
Information regarding migraine and PT is lacking in
the literature. The objective of this study was to examine
the prevalence of PT among patients with a migraine
diagnosis and to determine if migraine treatment
improved PT.
METHODS
The study is a single-institution retrospective medical chart
review. The author’s billing data (May 1, 2004 to December 31,
2014) of patients who received care at the Johns Hopkins Out-
patient Center Otolaryngology clinic were eligible for review.
This study qualified for institutional review board exemption as
approved by The Johns Hopkins Institutional Review Board.
Inclusion criteria included visit diagnoses of ICD-9
(migraine) and 388.3x (tinnitus). PT was determined if the chart
described tinnitus as pulsatile, pulse-like, or if the assessment’s
final diagnosis was PT. Tinnitus laterality was determined by
patient report. Patients were excluded if PT was attributed to an
alternate diagnosis noted on imaging or if ocular or cervical
vestibular myogenic potentials (o or cVEMPs) suggesting
superior canal dehiscence (SCD).
All patients were prescribed a strict migraine diet (see supple-
mental digital content, ) with or
without migraine medication. Addition of antimigraine medi-
cation was at the clinician’s discretion. Treatment adherence and
subjective tinnitus improvement was documented in the chart.
Presence of headache and comorbidities were determined from
patient report and medical record. Presence of sensorineural
hearing loss was noted on audiograms.
Address correspondence and reprint requests to Heather M. Wein-
reich, M.D., M.P.H., Department of Otolaryngology–Head and Neck
Surgery, Johns Hopkins Outpatient Center, 601N. Caroline Street, 6th
Floor, Baltimore, MD 21287, U.S.A.; E-mail:
The authors disclose no conflicts of interest.
Supplemental digital content is available in the text.
Otology & Neurotology
37 :244–247 2016, Otology & Neurotology, Inc.
Reprinted by permission of Otol Neurotol. 2016; 37(3):244-247.
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