102 / 264
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.
DISCUSSION
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
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.
TABLE 1.
Antimigraine medications and doses
Medication
Dose
Amitriptyline
15 mg q day
Diltiazem
120 mg q day
Nortriptyline
10–30 mg q day
Topiramate
50–150 mg q day
Venlafaxine
75 mg q day
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
2
5
0
8
Diet
þ
medication
0
1
4
1
6
Did not try diet
0
0
0
1
1
All patients
0
3
9
2
14
Two patients excluded as they did not have headache.
H. M. WEINREICH AND J. P. CAREY
Otology & Neurotology, Vol. 37, No. 3, 2016
81