Michael J Jacobson Md Otolaryngology 4 / 5 49 Reviews
Biomed Res Int. 2015; 2015: 797416.
Tinnitus and Headache
Berthold Langguth
1Department of Psychiatry and Psychotherapy, University of Regensburg, 93049 Regensburg, Deutschland
Verena Hund
1Department of Psychiatry and Psychotherapy, University of Regensburg, 93049 Regensburg, Germany
Volker Busch
1Section of Psychiatry and Psychotherapy, Academy of Regensburg, 93049 Regensburg, Deutschland
Tim P. Jürgens
2Department of Systems Neuroscience, Academy Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
Jose-Miguel Lainez
3Section of Neurology, Cosmic Academy of Valencia, 46010 Valencia, Espana
Michael Landgrebe
1Department of Psychiatry and Psychotherapy, University of Regensburg, 93049 Regensburg, Frg
4Department of Psychiatry, Psychosomatics and Psychotherapy, Kbo-Lech-Mangfall-Klinik Agatharied, 83734 Hausham, Germany
Martin Schecklmann
1Department of Psychiatry and Psychotherapy, University of Regensburg, 93049 Regensburg, Germany
Received 2015 May 6; Accepted 2015 Jul 21.
- Supplementary Materials
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Supplementary Material: Additional questions asked to the patients nigh the relationship between tinitus and headache
GUID: 7D6FEDD0-AEFC-442C-A0EF-301BE04CFCC3
Abstract
Background. Tinnitus and headache are frequent disorders. Hither, we aimed to investigate whether the occurrence of headache among tinnitus patients is purely coincidental or whether tinnitus and headache are pathophysiologically linked. We investigated a large sample of patients with tinnitus and headache to gauge prevalence rates of different headache forms, to determine the relationship betwixt tinnitus laterality and headache laterality, and to explore the relationship betwixt tinnitus and headache over fourth dimension. Method. Patients who presented at a tertiary referral center because of tinnitus and reported comorbid headache were asked to complete validated questionnaires to determine the prevalence of migraine and tension-type headache and to assess tinnitus severity. In addition, several questions nearly the human relationship between headache and tinnitus were asked. Results. Datasets of 193 patients with tinnitus and headache were analysed. 44.6% suffered from migraine, 13% from tension-type headache, and v.7% from both. Headache laterality was significantly related to tinnitus laterality and in the majority of patients fluctuations in symptom severity of tinnitus and headache were interrelated. Conclusion. These findings propose a significant relationship betwixt tinnitus and headache laterality and symptom interaction over time and argue against a purely coincidental cooccurrence of tinnitus and headache. Both disorders may be linked by mutual pathophysiological mechanisms.
1. Introduction
Tinnitus is defined every bit the perception of sounds in the absenteeism of a corresponding audio-visual signal. It is a frequent disorder, which is reported by about 10% of the population [i]. While some patients tin can habituate or larn to ignore the phantom sound, others are severely impaired past their tinnitus. Previous research has shown that comorbidities such as hyperacusis [2], hearing loss [3], insomnia [four], depression [5, half-dozen], pain syndromes [seven], and headache [viii, 9] play a major role in tinnitus-related impairment in quality of life [10]. Tinnitus-related impairment in quality of life tin be measured by specific validated tinnitus questionnaires such equally the "Tinnitus Questionnaire" [eleven] or the "Tinnitus Handicap Inventory" [12], simply besides by numeric rating scales [xiii, 14].
Like in headaches, idiopathic and secondary forms of tinnitus can be distinguished [fifteen]. Several pathologies can cause both symptomatic headache and tinnitus, such as carotid avenue dissections [sixteen, 17], arteriovenous malformations, traumatic encephalon injury, infinite occupying intracranial lesions, and intracranial hypo- or hypertension [xviii]. Interestingly, many patients with idiopathic tinnitus study headache syndromes every bit well [xviii, 19]. Since both idiopathic headaches and idiopathic tinnitus are frequent disorders [20, 21], this could be purely coincidental. However, a large population-based epidemiological study in elderly people identified a history of migraine as clinical chance factor for the development of tinnitus and suggested an interrelation between tinnitus and headache syndromes [22].
Moreover, there is increasing evidence that some forms of idiopathic headaches and tinnitus share similar pathophysiological mechanisms. Both animal studies and human imaging studies found that tinnitus is related to abnormal activity in the central auditory pathways as a effect of auditory deafferentation [23–25]. In addition to activity changes in central auditory pathways, alterations in a complex network of attention-, emotion-, and retentiveness-related encephalon areas have been demonstrated [xv, 26] resembling changes in a like network of cortical areas in chronic pain [23–25, 27]. Moreover, information technology has been proposed that hurting, headache, and tinnitus overlap in their pathophysiological mechanism by sharing specific alterations in thalamocortical activity [28–32]. These neurophysiological alterations which can exist detected as specific changes of oscillatory activity by magneto- or electroencephalography accept been described with the term thalamocortical dysrhythmia [29].
More than recently, brute studies have demonstrated that trigeminal input interacts at the dorsal cochlear nucleus with the activity of central auditory pathways [33] and tinnitus perception, as assessed by behavioural tests [34]. Further support for an involvement of the trigeminal organisation in tinnitus pathophysiology derives from the clinical ascertainment that many patients can modulate tinnitus action by face and jaw movements [35, 36]. Moreover, an clan betwixt temporomandibular joint disorders and tinnitus [37, 38] is well established and successful treatment of temporomandibular joint disorders was shown to improve tinnitus [39]. Naturally, an abnormal function of the peripheral and cardinal parts of the trigeminal system is a prerequisite for the germination of primary and secondary headaches, equally has been shown in migraine [40] and trigeminal autonomic headaches [41]. Finally, recent studies identified shared pivotal clinical symptoms in Meniere's disease and vestibular migraine such as episodic hearing impairment, tinnitus, and vertigo [42, 43]. Thus, both the central pain processing network (too referred to as the "pain matrix") and the trigeminal system stand for a common link in the pathophysiology of idiopathic headache syndromes and tinnitus.
To further investigate a potential human relationship betwixt idiopathic headache and tinnitus, nosotros asked patients who presented at the multidisciplinary Tinnitus Center at the Academy of Regensburg and who reported the beingness of headaches in the Tinnitus Case History Questionnaire [44] to complete a headache questionnaire [45, 46] and to answer additional questions about the relationship betwixt tinnitus and headache.
In detail, we aimed (one) to estimate prevalence rates of different headache forms amid tinnitus patients, (2) to investigate whether there is a relationship between tinnitus laterality and headache laterality in patients with unilateral tinnitus and unilateral headache, and (iii) to explore the relationship between tinnitus and headache over fourth dimension.
ii. Methods and Materials
2.1. Sample
The cross-exclusive observational study was based on datasets of all patients aged betwixt 18 and 90, who presented to the multidisciplinary Tinnitus Center of the University of Regensburg between 2003 and 2011 and whose data were included in the Tinnitus Research Initiative database [47]. All patients who reported the existence of headaches in the Tinnitus Case History Questionnaire (answer "yes" to the question, "Do you lot suffer from headaches?") [44] were contacted by mail and asked to complete additional questionnaires. Informed consent was obtained earlier inclusion into the report. The study was approved by the ethics committee of the Academy of Regensburg (11-101-0286). All data were pseudonymised before further analysis.
2.ii. Assessment of Headaches and Tinnitus Severity
In addition to the information available from the Tinnitus Research database [47], the actual tinnitus severity was quantified by the Tinnitus Questionnaire (TQ; Goebel 1994). According to the TQ score tinnitus severity can be classified as mild (0–30), moderate (31–46), severe (47–59), and farthermost (60–84).
For classification of headaches, the diagnostic headache questionnaire of Fritsche et al. [45] was used, which was developed and validated to meet the diagnostic criteria for migraine and tension-type headache, 2d version of the classification criteria of the International Headache Club (ICHD-2). The questionnaire enables differentiating migraine, tension-type headache, cluster headache, combination of migraine and tension-type headache, combination of tension-type and cluster headache, and nonclassifiable headache with very good exam-retest reliability (0.95). Validation of the questionnaire in a tertiary headache clinic [48] and in a population-based sample [46] revealed that sensitivity and specificity of the questionnaire are sufficient to diagnose migraine and tension-blazon headache, but not trigeminal autonomic cephalgias.
Boosted questions regarding headache frequency, headache medication, and the temporal relationship between tinnitus and headache were asked (Table 1; questions are provided in Supplementary Fabric available online at http://dx.doi.org/10.1155/2015/797416). Questions 29 and thirty of the Supplementary Material asked whether the onset of tinnitus influenced headache and vice versa. Nosotros combined these two questions into 1 variable whether offset of the 2nd symptom influenced the first symptom.
Tabular array 1
Prevalence and clinical characteristics of the unlike headache types (co-ordinate to the questionnaire classification of Fritsche et al. (2007) [45]).
| Headache type | North (% of whole sample) | Chronic (% of all patients with this headache form) | Episodic (% of all patients with this headache form) | Days with headache/month | Patients with medication intake (% of all patients with this headache form) | Days with medication intake/month |
|---|---|---|---|---|---|---|
| Migraine | 86 (45%) | xiv (16.3%) | 72 (83.7%) | 9.nine ± 9.3 | 66 (77%) | 8.6 ± xi.9 |
| Tension-type headache | 25 (13%) | vii (28%) | 18 (72%) | 12.viii ± eight.vii | 16 (64%) | 5.1 ± 3.v |
| Trigeminal autonomic headache | viii (4%) | ane (12.5%) | 7 (87.five%) | 8.5 ± 5.8 | 7 (87.5%) | thirteen.7 ± 27.2 |
| Migraine and tension-blazon headache | 11 (6%) | Migraine: 2 (18.2%) Tension-blazon headache: 3 (27.3%) | Migraine: 9 (81.8%) Tension-type headache: eight (72.7%) | 13.ane ± 10.0 | viii (73%) | seven.half dozen ± 7.0 |
| Nonclassifiable headache | 63 (33%) | n.a. | n.a. | 7.8 ± 6.nine | 43 (68.2%) | 8.four ± 8.6 |
2.3. Statistical Assay
The frequencies of the different headache forms and of the common interaction between tinnitus and headache in the sample were analysed descriptively. The relationship betwixt tinnitus laterality and headache laterality was analysed by a Chi-square test of independence. The influence of a mutual interaction between tinnitus and headache on tinnitus severity was analysed past a one-factorial ANOVA. In case of significant results Fisher's least significant deviation (LSD) post hoc tests were performed. A p value of <0.05 was regarded as statistically meaning.
iii. Results
489 out of 1817 patients reported headaches in the Tinnitus Case History Questionnaire. All these 489 patients were contacted. 225 (46%) answered and 193 datasets were analyzed (for more than information, see Figure one).
Data menses diagram of the questionnaire survey.
The 193 participating patients (117 (60.6%) female person, 52 ± 12 years) suffered for 97.iii ± 110.1 months from their tinnitus; their TQ score was 45.5 ± 18.3. 79 patients suffered from unilateral or predominantly unilateral tinnitus (51 left-sided, 28 right-sided); in 111 patients, the tinnitus was either on both sides or in the head (nonunilateral); iii patients provided no information apropos tinnitus laterality.
According to the headache questionnaire, 86 (45%) patients suffered from migraine, 25 (xiii%) from tension-type headache, 8 (4%) from trigeminal autonomic headache, 11 (6%) from migraine and tension-type headache, and 63 (33%) from nonclassifiable headache (for more details about clinical headache characteristics, see Table 1).
There was a significant human relationship between headache and tinnitus laterality (χ 2 = fifteen.490; df = 4; p = 0.004), even if among the headache types only the trigeminal autonomic headache is strictly side-locked. In all nonunilateral, left-sided, and correct-sided tinnitus, the corresponding headache types were more oftentimes encountered (see Figure 2).
Prevalence rates of patients with headache laterality depending on tinnitus laterality (displayed as pct of all patients with a given tinnitus laterality). In all nonunilateral, left-sided, and right-sided tinnitus, the corresponding headache types were more frequently encountered.
When asked near onset of tinnitus and headache, 67 (34.7%) patients reported tinnitus onset earlier headache onset, 106 (54.nine%) patients reported headache onset before tinnitus onset, and 20 (ten.4%) patients reported simultaneous onset. 101 (57.four%) patients reported that the onset of the second symptom did not influence the first; 60 (34.one%) patients reported worsening of the starting time symptom and in 15 (8.5%) the second symptom attenuated the first symptom. These iii groups differed significantly in their TQ scores (F = nine.077; df = 2,162; p < 0.001) with the highest TQ scores in those patients in which the second symptom either increased (TQ: 50.93 ± eighteen.96; p < 0.001) or attenuated (TQ: 55.43 ± xiii.12; p = 0.003) the first symptom, equally compared to those without whatsoever alter (TQ: 40.xiii ± 17.65).
Asked about an ongoing human relationship betwixt tinnitus and headache, 82 (43.4%) reported that worsening of tinnitus was related to worsening of headaches and vice versa, and nine (iv.8%) patients reported an inverse relation (worsening of tinnitus related to comeback in headaches and vice versa). 79 (41.eight%) reported no and 19 (ten.1%) another relationship between tinnitus and headaches. Patients with an ongoing relationship betwixt tinnitus and headache had higher TQ scores (positive human relationship: 49.48 ± sixteen.76; inverse relationship: 45.44 ± 13.99; some other relationship: 46.59 ± 19.04) than those without such a relationship (39.47 ± 19.06). ANOVA showed a significant main effect (F = 4.002; df = 3,173; p = 0.009) with a significant divergence between the group with positive clan and the group with no association (p = 0.001).
iv. Give-and-take
In order to explore a potential relationship between tinnitus and headache we systematically investigated the occurrence of different headache types in a large sample of tinnitus patients. For this purpose, we used a self-report questionnaire, which has previously been used as a screening musical instrument in an epidemiological report in Frg [20] and in a study that analysed the relationship between headache and low-dorsum pain [49]. In our sample of tinnitus patients, the proportion of tension-type headaches (19% of all headache patients) was clearly lower than the proportion of tension-type headache in the general population (44% of all headache patients [20]). The proportion of migraine patients in our sample was like to that in the general population (50% of all headache patients in our sample every bit compared to 52% of all headache patients in the general population [20]) whereas unclassifiable headaches were slightly more frequent than in the general population (33% in our sample equally compared to 26% in the general population [20]).
Our results demonstrate the feasibility to assess headache subtypes among tinnitus patients by using self-report questionnaires. Nonetheless, we are also well aware about the shortcomings of the chosen approach. Get-go, in the comparing of prevalence rates between our sample and the population-based survey, it has to be considered that the prevalence of the different headache forms depends strongly on historic period and gender, but the historic period and gender distribution of the tinnitus sample is not representative of the population. Second, we cannot exclude a pick bias and a reporting bias, since we only contacted tinnitus patients, who had presented at a tertiary tinnitus dispensary and who had reported the beingness of headaches, when they presented at the tinnitus clinic. Third, the retrospective design and the symptom assessment by questionnaires may be confounded by a remember bias. Fourth nosotros received completed questionnaires merely from about one-half of the patients, who had presented with tinnitus and headache in our clinic. The main reason for this relatively low response rate may have been that the interval between presentation in the clinic and contacting the patients was up to 8 years.
Considering of these limitations in a next footstep our findings should be complemented by case-control or population-based studies with prospective design and additional clinical test to confirm prevalence rates of unlike headache forms amongst tinnitus patients. Also patient samples presenting in headache clinics should be investigated for the presence of tinnitus to obtain complementary information from patients in whom headache is the main symptom. Face-to-face interviews volition enable a higher diagnostic accurateness particularly in patients with trigeminal autonomic cephalgias, in whom the validated questionnaire has but limited specificity [46, 48].
To our cognition, our study is the offset that studied the local and temporal relationship between headache and tinnitus in item. Here we found a highly significant association between tinnitus laterality and headache laterality. An even higher correlation might be obtained by asking explicitly for side changes of headaches and tinnitus, which we did non do in this report. It may also exist warranted to specifically screen for vestibular migraine, which may mimic Meniere'south disease [42] and which can cause both tinnitus and headache.
With respect to symptom onset, more patients reported that headache onset preceded tinnitus rather than the opposite and only a small-scale proportion reported that both symptoms started simultaneously. These findings were expected as headache typically starts at earlier age than tinnitus.
Thus, nosotros observed a highly significant association betwixt tinnitus and headache localisation and diverse possible temporal associations of the onset of the ii symptoms. These information fit with the assumption that headache and tinnitus are linked via common pathophysiological mechanisms. Equally headache precedes tinnitus in the bulk of cases one could assume that headache can trigger tinnitus. But tinnitus can besides trigger headache or a 3rd factor may predispose to local susceptibility (east.g., left, right, or nonunilateral). Thus, one could imagine that a unilateral headache syndrome results in sensitization of the trigeminal system, which then facilitates the development of tinnitus. Likewise the reverse management (unilateral tinnitus sensitizing the trigeminal organisation and resulting in headache on the same side) is possible. Finally the susceptibility to both symptoms may exist caused by a third cistron, for example, a unilateral trigeminal pathology, a globally increased sensitivity for nonunilateral headache and tinnitus in the context of a somatization disorder, or an increased genetic susceptibility for developing thalamocortical dysrhythmia [29]. Further electrophysiological and neuroimaging studies volition be needed to place the neuronal link between both disorders.
Most half of the asked patients reported that fluctuations in the symptoms are related to each other. In the vast majority of these cases worsening of ane symptom went along with worsening of the other symptom, only there were also cases with a reciprocal interaction or a more complex relationship. Such a relationship of symptom severity over time is a further indicator for a pathophysiological link between tinnitus and headache. Patients reporting such a human relationship had a significantly higher tinnitus severity equally compared to patients where fluctuations of tinnitus and headache were not related. Since a relationship of the two symptoms over time tin can only be detected, if symptoms are fluctuating, the result is confounded past the existence of symptom fluctuations. Further studies are needed to distinguish whether fluctuations per se are related with college symptom severity or whether it is the interrelation between headache and tinnitus that is responsible for higher tinnitus severity. It might exist of particular interest to investigate those patients who reported a reciprocal interaction between tinnitus and headache, since the mechanisms of this interaction may provide hints for potential therapeutic interventions. While an increase of tinnitus during migraine attacks has been reported before [50, 51], a reciprocal interaction has not even so been described before.
In summary our findings of a pregnant relationship between tinnitus and headache laterality and a temporal interaction of both disorders in the bulk of cases suggest that the cooccurrence of tinnitus and headache is not purely coincidental but that both disorders may be linked past shared pathophysiological mechanisms.
Supplementary Material
Supplementary Fabric: Additional questions asked to the patients about the relationship between tinitus and headache
Acknowledgments
The authors thank Susanne Staudinger and Sandra Pfluegl for their aid with data management.
Conflict of Interests
The authors have no conflict of interests, financial or otherwise, related directly or indirectly to the submitted piece of work.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4637068/
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