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Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

This episode is brought to you in part by our generous sponsor, Lilly.

Molly: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re talking all about migraine symptoms within the ear, and I’m very excited to introduce our guest today. He’s vice president and founder of AMD, Dr. Michael Teixido. Dr. Teixido, thanks so much for joining us today.

Dr. Michael Teixido: It’s a pleasure to be here, Molly.

Molly: Well, we’re really excited to have this conversation. Of course, always a pleasure to have you on Spotlight on Migraine. We’ll start off with the very basics. If someone’s experiencing migraine symptoms in the ear, what are some of these symptoms that might manifest during a migraine attack?

Dr. Teixido: Well, patients who typically have migraine may have symptoms that are recognizable only as migraine to them, but we see in our otolaryngology practice patients who come to us with ear symptoms. And we find out after discussing with them that, well, those symptoms are only happening at the same time that they started having more headaches. And they sometimes happen at the same time as their migraine headaches and sometimes independently.

So the common symptoms that are in the ear and for which they come to see us are ear fullness and pressure or pain; ringing in the ears, which may get worse at the time of a migraine attack or at the same time that their migraines got worse over the same period; dizziness, of course, which may be constant or episodic, and we’ll have time to talk more about that; and I think that that’s most of it. And in some patients, hearing loss, but that’s when their migraine is connected to other more direct inner-ear problems, problems like Ménière’s disease, which is an inner ear problem but it is strongly associated with migraine.

Molly: OK. It’s always fascinating to learn this stuff, and I’m assuming some people listening at home are going, “Hey, I have that, and it usually happens with migraine.” So I’m wondering, what do we know about why these symptoms exist? How come sometimes people might get some of these symptoms like dizziness or ringing in the ear or ear fullness?

Dr. Teixido: Well, one thing we need to remember is that the inner ear is an organ that is innervated. But we always think that they’re just innervated by hearing nerves and balanced nerves, but it actually has innervation just like your hand or your face or any other part of your body with sensory nerves. That is to say, your ear can feel. And the nerve that innervates the inner ear itself is the trigeminal nerve, the very same nerve whose hyperactivity is recognized as migraine activity.

So if you have a hyperactive trigeminal nerve and you have migraine, it’s easy to know that you have a migraine headache if all of your symptoms are up here in your head. But as we’ve discovered, a lot of patients — that that same trigeminal nerve has branches in the face and in the teeth and in the jaw. And if you have symptoms in those branches of the trigeminal nerve, we think we have sinus symptoms. The notion of headache doesn’t occur to us. 

If you have hyperactivity in branches in the back of the head or in the neck, we think we have a neck problem, whereas, really, a lot of migraine patients, they just happen to be wired so that their migraine activity is back there.

Well, many patients, they’re wired in a way that they get a lot of symptoms in the sensory branches that are in and around the ear. So they don’t realize they have migraine, but they think they have ear problems, ear infections, or maybe TMJ problems, which, in fact, they’re just having hyperactivity in the trigeminal nerve but that seems to be centralized in those nerves that serve the inner ear and the outer ear, even.

Molly: It’s fascinating. The more we learn about migraine, we can understand all the complex connections that are within this complex disease.

Dr. Teixido: That’s right, yeah.

Molly: So I’m wondering, and I know this is kind of basic, but can people have these types of symptoms without experiencing a full migraine headache aspect?

Dr. Teixido: Yeah. In fact, that’s really important because we all — it’s nice to know what a migraine headache is, and we all have an idea of what a migraine headache is, this very intense unilateral headache with light sensitivity and sound sensitivity, and you have to go lie down and put your head under a pillow. Well, yes, that’s a migraine headache, but that’s only one kind of migraine headache, and it’s the kind that most people have heard about. And that knowledge of that one kind of migraine headache has another back edge to it that is detrimental. We think that anything that doesn’t meet that kind of model isn’t a migraine.

And, in fact, there are hundreds of kinds and manifestations of migraine, and every patient has their own. And so people think that, no, if it’s not intense, it can’t be a migraine, or if it isn’t on one side of the head that it can’t be a migraine. Well, that’s just not true. And, in fact, the best way to think about a migraine is that a migraine is any headache, mild or severe, with other symptoms, with other neurologic symptoms — with tinnitus, with dizziness, with visual changes, with GI symptoms.

And as we’ve learned more and more, we find that the head pain, the cardinal symptom of migraine, doesn’t even need to be present. And that’s when it gets really more tricky. It’s more of a diagnostic dilemma. So if you always get these ear symptoms at the same time as you get your headache and they always come together and go away together, well, the correlation with migraine isn’t very difficult to make, or with headache isn’t difficult to make.

But if the ear symptoms come and go on their own and there’s no headache at the same time, that cardinal symptom is missing. Then what you are more likely to find is that those symptoms are coming and going with recognized migraine triggers. They’re coming and going at times when you’re fatigued, when you’re dehydrated, when the weather is changing, when there’s stress, or with particular foods, or allergy exacerbations. All of these things are classic triggers for migraine activity, and they can be classic triggers for these atypical symptoms of migraine.

There’s a good general word for these other kinds of symptoms, and that’s “migraine equivalents.” They’re equivalent to migraine. They behave like migraine, even though they don’t look like classic migraine.

Molly: It can be tricky because if you don’t have that headache but you have all these symptoms in the ear and you don’t really know about migraine, it can be very confusing, I imagine.

Dr. Teixido: That’s right. I frequently have patients who believe that they are the one person in their family who didn’t get migraines. “My mom has migraine. My dad has migraine. I have three sisters and a brother who all have migraine, but I didn’t get it.” But here they are in my office talking about their dizziness, and their dizziness is their migraine.

Molly: I’m sure that helps to get a little family history. That helps to fit the puzzle together.

Dr. Teixido: It does. That’s right. A lot of patients do have it.

Molly: So let’s talk about treatments. What treatments are available for the symptoms of migraine that appear in the ear?

Dr. Teixido: Well, the treatments are the same as for patients who have migraine headache that is chronic. So if you have symptoms all the time, it’s better to just prevent them from happening than to try to catch up with them and put out these fires day by day. And the way we manage this in patients with chronic migraine is with migraine preventive medications. And what those do is stabilize the central nervous system so that the threshold for triggering goes higher and higher — but also with trigger identification and avoidance.

Now, if you’re having symptoms every day, it’s hard to tell what your triggers are. So we usually start out with some medication to elevate the threshold, but then we reduce triggers, at least the obvious ones. So it’s hard to control stress sometimes. You can’t control weather changes. We can’t control hormones. We can completely control the foods that we put into our bodies. And so I tell people to avoid obvious migraine triggers and to cut down on strong triggers like caffeine, chocolate, red wine, but not to go too far. The idea is to reduce the food triggers by about 70 to 80 percent.

Why not go 100 percent? I’ll tell you why. It’s because the most potent trigger for migraine activity is stress, and trying to eliminate food triggers 100 percent using a big list that was accumulated from thousands of people, only a few of those triggers probably apply to any individual patient. And trying to follow that list 100 percent is stress generating for the patient, for their family. 

You never want to be sitting there with your patient, sitting there in the restaurant with their list. It’s all about them and their list, or they can’t eat the food that their family has prepared for them because they are objecting in their list. That’s stress. Let’s forget that. So let’s not be black and white.

And then the other thing is just general lifestyle change. A lot of times, patients who have an emergence of these new kinds of symptoms that are chronic, whether it’s headache or ear symptoms, we find that, yeah, they’ve been really fatigued. They’ve been sleeping terribly for one reason or another, or they have a big stress, or they have allowed themselves to get dehydrated all the time. That’s a common trigger. 

So we treat these symptoms the same way that we treat patients who have chronic migraine headache — with lifestyle changes, diet modification, and preventive medications. And why not just start small? Well, the reason that we don’t start small is there is a phenomena of chronification. Maybe the lifestyle changes will work right away, but maybe not. And so someone tries with diet, and that doesn’t work, and then you try lifestyle modification, and that doesn’t work with the diet. And then, finally, you get around, nine months later, to using these medications after a few appointments. Well, that’s nine months of time during which the brain is actually practicing and burning in these pathways. And, in my mind, those symptoms get more durable, more resistant to treatment as they are becoming more established and the brain is repeating activity.

So the way I think about stopping these symptoms is that, “Look, we’re going to put your brain in reform school. It has a very bad habit. It’s not going to happen over a weekend, but over a semester or two of really suppressing the symptoms, your brain will stop defaulting to this. And you’ll get to a point where you’re so well treated that you’re asking the very reasonable question, “I wonder if I still need this medicine?”

And that’s exactly when we start backing it off, seeing if the coast is clear, backing it off a little bit more, and month by month we get off the medication. And about half the time, if we’ve really controlled things for six months or more, patients get off their medication. They have occasional symptoms, and when they do have symptoms, they know what it was.

Molly: Retraining that brain on how to process.

Dr. Teixido: Yeah, that’s right.

Molly: So thank you for sharing all that, some things that we can do ourselves as migraine patients and then along with working with our doctor our healthcare provider to find some treatment. So there are options out there. 

Let’s talk a little bit about dizziness. So some people have migraine-related vertigo, and then some people have vestibular migraine. Can you explain the difference between the two?

Dr. Teixido: Well, vestibular migraine is a diagnosis which is really a misprocessing of normal balance information that comes from the inner ear after it goes to the brain. So imagine the inner ear is working perfectly normally, but it gets to the brain, where it gets processed, and the processing gets messed up. And we get symptoms that can seem like symptoms that can come from the inner ear, like spinning vertigo, or we can get little episodes of disorientation, like an invisible man just shoved us.

Or we can get other symptoms that cannot come from the inner ear, a symptom like being displaced in space as if you’re looking at the world from a foot behind where you’re actually sitting. We call that the Alice in Wonderland syndrome. That’s a symptom that comes probably from the thalamus, where awareness occurs.

Another characteristic symptom that separates central dizziness from something that happens in the inner ear are patients who have a constant rocking sensation. Even though they’re sitting still, they feel that they’re rocking back and forth. Once again, this is not a symptom that can be generated in the inner ear. So we know it’s coming from the central nervous system and is more likely to respond to migraine therapy than to any kind of therapy directed at the inner ear. So that’s vestibular migraine.

Now, another term that you used is migraine-associated vertigo, in my mind, suggests a group of patients who have inner ear disease that is provoked by migraine. I mean, as I mentioned, the inner ear is innervated by the trigeminal nerve fibers. It’s very sensitive. The patients with migraine are wired in all different ways so that they can get activity in their face or in their head or in the neck or in the inner ear. And if in a migraine episode, the inner ear has these blood vessel changes and the secretion of inflammatory mediators like CGRP, well, those can actually injure the inner ear.

We now know that about half of the patients who get the benign positional vertigo, loose crystals in the inner ear, they get the BPPV at the start — it all starts with a strong migraine headache in about half of cases. And patients with migraine are about seven and a half times more likely to get loose crystals, BPPV, than other patients. So that’s pretty strong testimony that the inner ear can be injured like an innocent bystander during migraine activity.

Now, the same is true of Ménière’s disease. Ménière’s disease — the incidence of migraine in the general population, the prevalence is about 13 percent. Well, if you get a room full of patients with Ménière’s disease and you find out how many of them have migraine, it’s about 55 percent of them have it. And if they have Ménière’s disease in both ears, it’s about 85 percent. So it’s not likely a coincidence.

It’s likely that in some susceptible individuals, the migraine activity is injuring their inner ear and that the inner ear eventually gets so injured that it takes on a life of its own. It just doesn’t work right. It works like a jalopy of a car. It’s constantly backfiring, making noise, swelling, having vertigo episodes. But it also acts up when it gets another wave of migraine activity coming through. And that wave of migraine activity may have been the very injury that caused it to go bad in the first place.

So there are two distinct categories of patients: those who have migraine activity that has created real inner-ear disease that is related to the migraine, and other patients who have a migraine activity in a portion of their brain that creates an abnormality of vestibular processing, and that creates symptoms that sound just like inner ear disease, because dizziness is dizziness and it’s hard to describe. But it also creates some of those extra symptoms that are unique, that can’t even be created in the inner ear, like the rocking and displacement in space that I talked about.

Molly: We have some questions from our followers, if you’re up for it.

Dr. Teixido: Sure, sure.

Molly: OK, great. So this person says that both of their ears itch after a migraine. They’re wondering what may cause that and if there’s a way they could get rid of it.

Dr. Teixido: Well, that’s an interesting issue. I think that if that happens frequently, you can take an antihistamine. When a migraine attack occurs, CGRP is secreted from these C-fibers around the blood vessels both on the surface of the brain and in the inner ear and in tissues. And that CGRP locks on to receptors that are also present on mast cells. Now, what is a mast cell? It’s a part of our immune system, and it’s filled with histamine, and it causes histamine to be released. And so if you get histamine release, so you’re going to itch.

And so a patient who has migraine has higher histamine levels than a patient who doesn’t have migraine. And a patient who has migraine who’s having a migraine attack, their histamine levels are really, really high during the attack. So some patients actually can have symptoms that can be reduced during a migraine attack just by taking an over-the-counter antihistamine, and itching is one.

Molly: That is very helpful, I’m sure, for quite a few people out there. So you talked a little bit at the beginning of our conversation about that ear fullness, and this person wants to know, “Why do ears feel full?” Is that just a symptom like we’ve already kind of gone over?

Dr. Teixido: Well, the way to think about ear fullness is that it’s ear pain. It’s just ear pain that’s turned down to a level of 1 out of 10. You can tell it’s there. It feels full. You can’t make it go away. You pop your ear, and it doesn’t change. It doesn’t eliminate it. Your doctor tries to put a tube in the ear; it doesn’t change it or improve it. 

And after a while, you realize, well, it is just having a mild headache, like people get pressure in their forehead. It’s not even in the outer ear and the tissues here, but it’s deep inside, in the inner ear itself. So we tend to treat this, once again, with these preventive medications to try to calm down the nervous system.

Molly: It’s fascinating to think about like that. Just a little bit different perspective, I think, and then it makes sense. And we talked about structural changes.

So that wraps up our viewer questions. I’m wondering, Dr. Teixido, is there anything else that you want people to know about migraine and symptoms that happen within the ear?

Dr. Teixido: That happened within the ear? Yeah, I think that one area that is interesting is that when we get irritability — we also have muscles in the ear, and those muscles are there to pull on the hearing bones and to make them stiff when we’re in really loud situations. So we measure those muscle reflexes with — we call them stapedial reflex testing. And we have patients who come to us who are having spasms of those muscles. We call it middle ear myoclonus.

And I think some people have experienced a little twitching under their eye. Well, imagine if that was happening in one of the muscles in your ear. It would feel like there was a moth or something in your ear. Well, almost every patient I’ve met who has this middle ear myoclonus actually has headache, and they’re having some actual irritability in there and spasm of one of the muscles. And one of the two muscles is innervated by the trigeminal nerve. So just like we get chronic tension in our masseter muscle and temporalis muscle — these are also innervated by the trigeminal nerve — if you get too much tension in the tensor tympani muscle in the middle ear, you can get this myoclonus.

And I get patients who call me, and they ask — they’re searching for a doctor — “Do you cut the tendon for this problem?” And, usually, they come to see me to have an operation to cut the tendon to stop this. And what I really do is I find out that they have migraine headaches about four to five days a week. We take away their migraine, and then that myoclonus just goes away. So that’s one interesting symptom that I think is in the ear that patients would be — it’s worth knowing about.

Molly: No kidding. You go in for an operation, and you get treatment — not bad, not bad to figure that out.

Dr. Teixido: That’s right, yeah. And I think the other thing to recognize is that you can get treated for — in patients who have migraine-associated vertigo, who have inner ear disease, like Ménière’s disease or BPPV — you can keep on getting treated again and again for those problems, and the attention turned to the inner ear is correct. But if they are recurrent, you have to stand back, and it’s worth asking your physician, “Listen, is there a reason that I keep getting this, and would calming down the nerves that innervate the inner ear be helpful in my treatment?” And almost always the answer is yes. The difficulty is finding a physician who sees the problem that way.

And the way I look at it is that when you’re just treating the ear again and again, that’s like fixing the nose of a boxer who will not stop the boxing. And so if you can fix his nose but also prevent him from going back in the ring and getting beat up again, you’re going to have a better long-term outcome.

Molly: That’s a great analogy there to put it in perspective. Well, this has been so informative. I know I’ve learned a lot. I hope you watching and listening at home have learned a lot as well. So I’d like to thank our guest, Dr. Michael Teixido. He is AMD vice president and founder. Thank you so much for joining us today.

Dr. Teixido: Well, thank you very much, Molly. It’s my pleasure to talk about these symptoms with all of our viewers. I hope this has helped.

Molly: I think it definitely will help folks out there.

So that wraps up this episode of Spotlight on Migraine. We appreciate you watching and listening. Thank you so much for joining us. I’m Molly O’Brien, with the Association of Migraine Disorders, and we’ll see you next time.

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Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.