HSC Section 8_April 2017

Reprinted by permission of Otol Neurotol. 2016 ; 37(3):244-247.

Otology & Neurotology 37 :244–247 2016, Otology & Neurotology, Inc.

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

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. 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. 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-9 346.xx (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, http://links.lww.com/MAO/A363) 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. METHODS Otol Neurotol 37: 244–247, 2016.

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 346.xx 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. 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

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: hweinre1@jhmi.edu The authors disclose no conflicts of interest. Supplemental digital content is available in the text.

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