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Headache in Meniere’s disease
Auris Nasus Larynx 26 (1999) 427 – 433 www.elsevier.com/locate/anl
Headache in Meniere’s disease Susanna Eklund * Department of Otolaryngology, Uni6ersity Hospital of Helsinki, POB 220, FIN-00029, Helsinki, Finland Received 8 October 1998; received in revised form 17 January 1999; accepted 12 March 1999
Abstract Objecti6e: We examined headache in 86 patients with severe or moderately severe Meniere’s disease (MD) or with Meniere’s syndrome (MS) chosen for intratympanic gentamicin treatment. Forty-five patients with vestibular neuronitis (VN) served as a control group. Methods: In addition to a clinical examination, the patients filled out a questionnaire concerning their headache. Results: Altogether 60 MD patients (70%) and 26 VN patients (58%) reported headache. Headache was severe in 35 MD patients (58%), moderate in 16 patients (27%) and slight in nine MD patients (15%), and as a whole more severe than that of the VN patients (PB0.01). The MD patients exhibited significantly more occipital (P B0.005) and neck headache (PB 0.005) than the VN patients. Analgesics had been used by 82%, antidepressants by 35%, sumatriptan by 13% and carbamazepine and/or amitriptyline by 12% of the MD patients suffering from headache. Pain relief was reported as good by 27%, satisfactory by 60%, poor by 5% of the MD patients and 8% could not rate the pain relief. In this study migraine was diagnosed in 5 MD patients. Conclusion: It is concluded that MD is associated with headache that can be handicapping, and tricyclic antidepressants with pain alleviating medication is often needed to treat the headache in MD whereas sumatriptan did not alleviate the headache of the non-migraine patients. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Headache; Pressure; Meniere’s disease; Migraine; Vestibular neuronitis
1. Introduction A link between Meniere’s disease (MD) and headache was already reported by Prosper Meniere [1]. Various authors since have discussed the possible relationship between migraine and MD [1 – 11]. Both are episodic in nature, and often create an otoneurologic disorder consisting of vertigo spells, tinnitus, and alteration in hearing. The discrimination of peripheral labyrinthine disorders * Fax: + 353-0-4715094. E-mail address: [email protected] (S. Eklund)
and migraine has been difficult in several cases [2]. Rassekh [3] studied the difference in migraine prevalence between classic MD patients and those with only vestibular symptoms. He showed that the prevalence of migraine in classic MD was greater (22% of 46 patients) than the prevalence of migraine in the general population. Stewart et al. [4] studied the prevalence of migraine in the population of the United States and found that 18% of adult women and 6% of adult men have migraine. In a retrospective study of 85 patients with MD, Parker [5] found a higher incidence of migraine (34%) in MD than in the general popula-
0385-8146/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 9 9 ) 0 0 0 2 2 - X
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S. Eklund / Auris Nasus Larynx 26 (1999) 427–433
tion. Parker [5] and Atkinson [6,7] stated that the symptoms in MD could result from vascular spasm of the inner ear vessels, similar to the presumed etiology in migraine. Hincliffe [8] reported headache in 75% of 42 patients with MD. Since the patients had scotomata, the headache was believed to be of migranous variety. Dolowitz [9] observed episodic headache in 83% of 125 patients with MD. He found that headache was a relatively independent symptom in vertigo patients, but associated with positional vertigo. The patients did not mention headache as a part of the disease, but when it was included in a questionnaire chart its presence became very obvious. Gilbert [10] reported cluster headaches in three patients with MD. He postulated that the same mechanism might precipitate the cluster headache and the MD in these patients. Johnson [11] treated 24 patients with a diagnosis of migraine-related dizziness with objective fluctuating hearing loss pharmacologically. When medical therapy was directed at the migraine using either benzodiazepins, tricyclic antidepressants, propranolol, selective serotonin reuptake inhibitors, amitriptyline or nortriptyline; the symptoms of migraine either completely resolved or improved substantially. In the study of Evans et al. [12], 31% of the patients with MD had a history of classical migraine headaches. In their study, 68% of the migraine patients had one or more autoantibodies present. Recently Kentala [13] reported that 64% of 107 patients with MD had headache and 47% had symptoms of paresthesia of the face and occiput. In objective evaluation their sensitivity appeared to be normal. Moskowitz [14] and Vass et al. [15,16] have demonstrated the existence of neural connections between the trigeminal nerve and the cerebral blood vessels defined as the trigeminovascular system. They hypothesised that neurogenic sterile inflammation of the intracranial and extracranial vasculature, mediated through the trigeminovascular reflex, is causing the headache [15 – 17]. The trigeminal innervation to the cochlea is known to be involved in endolymphatic hydrops [15], and may cause even the otoneurological symptoms in Meniere’s disease. Sumatriptan (5-HT-agonist) helps patients with migraine pain in 70 – 85% dur-
ing any moment of the attack [18], but no such reports are available on patients with headache in MD. The purpose of the study was to evaluate the incidence of headache and pressure in patients with severe and moderately severe MD. We also tried to explore the characteristics and localisation of the headache by reviewing 86 patients with MD treated with gentamicin. The use of painkillers and pain alleviation by different methods was queried. In open trial eight patients were treated with sumatriptan. As headache is a common ailment in the general population, we chose a group of patients with vestibular neuronitis (VN) as the control group.
2. Methods From a larger group of patients with MD in the study period 1987–1993, 89 patients with severe or moderately severe MD (criteria based on the American Academy of Otolaryngology-Head and Neck Surgery 1985) were selected for the present study. Also five patients with delayed hydrops were included in the study. Both MD patients and patients with delayed hydrops took part in a larger survey on the efficacy of gentamicin applied transtympanically [19]. A follow-up questionnaire concerning headache was sent to 91 surviving Meniere patients: 67 women and 24 men during September 1994 in order to chart out the characteristic features of headache and the treatments for it. Of the 91 surviving patients 86 (95%) replied to the questionnaire. The mean age of the patients was 50.9 years (range 19–74 years) and the mean duration of MD was 9.8 years (1–33 years). Subjects with occasional headache were classified into the non-headache group. Thus, eight patients who had headache only once or twice a year, and did not experience their headache as troublesome, were excluded from the headache group. The same questionnaire was administered to a control group of 60 patients with VN, and referred to the balance laboratory of the ENT department. In the questionnaire, the severity of the headache was classified as no, mild, moderate and
S. Eklund / Auris Nasus Larynx 26 (1999) 427–433
severe. Of the 60 patients, 45 (76%) answered the questionnaire. The mean age of these patients was 45.9 years (range 12 – 74 years). Four patients who had headache only once or twice a year, and whose headache was not troublesome, were classified in the non-headache group. We used a modified McGill Pain Questionnaire [20] to describe the severity of headache. The questionnaire contained 54 different words in the major classes—sensory, affective and evaluative. The words were in groups containing three to six similar words characterising pain. The patients were asked to select from each group the words that characterised their symptom best. Also factors that provoke headache were asked. The medical records of the patients were reviewed in detail to find a connection between other possible causes of headache and medication. The patients were asked if they still had persistent headache, and what had been done to treat this pain. The detri-
Fig. 1. Area of the head pain in 60 patients with MD.
Fig. 2. Extent of headache of the 60 patients with MD.
429
mental effect of headache on the subject’s performance at work was also asked. Diagnosis of migraine was based on the International Classification Committee of the Headache Society (ICCIHS) [21].
2.1. Statistics The significance of the treatment on headache and various factors determining the severity of MD was sought in linear regression analysis. In searching for risk factors, a logistic regression analysis was performed. The x 2-test and the Fischer’s exact test were used to analyse the headache in the groups of MD and of VN and pain relief.
3. Results
3.1. MD patients Altogether 60 patients out of 86 with MD (70%) had headache. Of these 60 patients 46 (77%) had persistent headache and 15 (23%) temporary headache. The headache was felt mainly in the forehead (61%), the occiput (58%), and around the neck (38%) (Fig. 1). The headache was severe in 35 (58%) patients, moderate in 16 (27%) and slight in eight (15%) patients (Fig. 2). Only one of the patients had to change jobs because of headache, but 33 (56%) felt that their job performance or household tasks suffered because of their headache. In the McGill Pain Questionnaire, the headache was described mostly as disturbing sleep, onesided, disabling and numb (Table 1). Headache was associated with pressure in the head or postauricular region in 44 (73%)of the MD patients, with tinnitus in 41 (68%), with visual symptoms in 29 (48%), with nausea in 29 (48%), with vertigo in 26 (43%). Headache occurred daily in 16 (27%) of the MD patients, weekly in 18 (30%), monthly in 15 (25%) and less frequently in eight (13%) of the patients with MD. Altogether 26 (58%) of the patients with VN had headache. 42% of these patients had persistent headache and 58% temporary headache. The
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Table 1 Sensory and affective characteristics of the headache in 26 VN and 60 MD patients Type of headache (sensation)
% VN
% MD
Type of headache (affectiveness)
% VN
% MD
Pulsating Pounding Through Wavy One-sided Deep Stabbing Numb Strucking
47 10 27 10 43 20 13 7 13
13 17 30 25 37 25 21 36 11
Psychic Epileptic Annoying Sore Nauseating Disabiliting work Wearing Awakening Heavy
30 3 69 21 30 7 37 20 18
36 14 31 13 16 32 30 42 22
headache was mainly frontal (57%), and around the eyes (30%) (Fig. 3). The headache associated with nausea in 35%, pressure in the head or postauricular region in 31%, with visual symptoms in 31% and with vertigo in 19%. The headache was severe only in two patients (8%) (Fig. 4). The headache occurred daily in 4%, weekly in 40%, monthly in 46% and less frequently in 10% of the patients. The patients picked out 17 words characterising their headache from the questionnaire. The pain was described mainly as annoying, pulsating, onesided and wearing (Table 1). Eight percent of the patients had to modify their jobs because the headache was so incapacitating.
0.05). There was no statistical difference between the two groups in the sensory, affective or evaluative words characterising the pain evaluated with the McGill Pain Questionnaire.
3.2. Difference between the groups The patients with MD had more daily headache (PB0.005), they exhibited significantly more occipital pain (P B 0.001), neck muscle (PB 0.005) and ear pain (P B0.05) than the patients with VN. The headache caused difficulties in the sleep rhythm more often in the Meniere group (P B0.05), as well as work disability, than in the control patients (P B 0.005). Headache was related to pressure, tinnitus, nausea and vertigo only in patients with MD (P B 0.05). The severity of the headache caused more problems for the patients with MD than for the patients with VN (P B0.01). In the MD physical efforts such as bowing, were a statistically significant provoking factor for headache (P B
Fig. 3. Area of the head pain in 26 patients with vestibular neuronitis (VN).
Fig. 4. Extent of headache in 26 patients with vestibular neuronitis (VN).
S. Eklund / Auris Nasus Larynx 26 (1999) 427–433
Fig. 5. Experient of pain in 60 patients with MD.
431
tory drugs for headache, 21 (35%) had used antidepressants, and seven (12%) of the patients amitriptyline and/or carbamazepine. The latter two treatments constitute the treatment of choice for neuropathic pain today [22]. Of all the headache patients, 16 (27%) considered the pain relief was good (Fig. 5). Only 4% had tried to alleviate their pain with strong analgesics, 7% with physiotherapy, 4% with anxiolytics, and 21% with acupuncture. Sumatriptan was given in an open trial to eight patients without response. Acupuncture, physiotherapy and anxiolytics gave some help to eight patients, but worsened the headache of one patient. Of the 26 patients with VN who had headache, 21 (81%) had used non-steroidal anti-inflammatory drugs for headache and one patient had used antidepressants. Thirty-one percent had tried to alleviate their pain with physiotherapy, two patients with acupuncture and one patient with osteopathy. Of the VN patients 42% considered the pain relief was good (Fig. 6).
4. Discussion Fig. 6. Experience of pain relief in 26 VN patients treated with analgesics.
3.3. Risk factors for headache in MD A significant correlation was found between persistent headache and working capacity (r = 0.663, PB 0.001). A logistic regression analysis was tried to search for risk factors predicting severe and persistent headache. The following models were included in the model: sex, ELS surgery, unsteadiness, severity of rotatory attacks, outcome of caloric responses, severity of Tumarkin otolitic attacks, pressure in the ear, tinnitus, and overall handicap. With the maximum likelihood method, no factor as such predicted persistent headache.
3.4. Therapy Of the 60 Meniere patients who had headache, 49 (82%) had used non-steroidal anti-inflamma-
The high response rate of 95% to the questionnaire suggests the extent of problem with headache treatment among the Meniere patients. The incidence of headache in 70% and the persistent headache in 77% of these headache patients prompted the patients to answer. In our study, 43% of the patients experienced vertigo associated with headache, which is significantly more than in the study of patients with migraine-related vertigo [11] (9%). This finding may reflect the selection of patients with more severe MD in our study. It may also indicate that the same disturbance in the sensory trigeminal system may trigger vertigo and headache in MD. The previous contenders [3,5–8] for a high prevalence of migrainous aetiology did not receive support in the present study, as the incidence of migraine was only 6% that is comparable to 8% in the general population [21]. Sumatriptan (a 5-HTagonist) has proven effective in aborting migraine headaches [18]. In an open trial, eight patients in
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this study were given sumatriptan without response. Our results confirm the study by Cass et al. [23] in which they suggest that the relationship between migraine and MD seems to be a matter of chance than a positive association. Headache was associated with a feeling of pressure in the head or postauricular region in 72% of the patients. The persistent headache, despite the use of painkillers, in 77% of the patients is typical of neuropathic pain. In neuropathic pain relief, antidepressants and/or amitriptyline constitute the treatment of choice today [22] as they reduce the frequency and severity of headache in migraine patients [11]. It has been suggested that the antimigraine effect of amitriptyline is mediated through the stabilisation of serotoninergic transmission [24]. It was rather disappointing to find out that only 12% of the patients with headache had received amitriptyline and/or carbamazepine. A difference was found in the severity of headache between the patient groups. Severe headache was present in MD in 58%, whereas in the VN group in only 8% of the patients. It is not possible to compare this with other studies, because they did not grade the severity of headache with other patient groups. The short duration of effectiveness of analgesics was reported more often by Meniere patients, too. The findings thus confirm earlier observations that in the disease entity of MD, headache is one of the significant components and should thus be included in the associated symptom list with the same weight as, for example, pressure in the ear. Headache occurred daily in 27% of the MD patients, and in only 4% of the control group. The ability to continue working was not reduced in the control group, while for the MD patients headache was a disabling factor. Tension headache is a common type of headache caused by tension in the receptive fields from the three cervical nerves. The muscles, joints and ligaments have been shown to be capable of causing headache [25]. Although seven of the 11 MD patients with self-reported neck muscle contraction had tried to alleviate pain with acupuncture, physiotherapy or anxiolytics, the headache had persisted in all of them. The pain type in four of these MD patients was deep, penetrating,
sharp, or pounding, and accompanied by numbness and tenderness in the pain area. Although the description and localisation of the pain point to tension headache in these patients, they had no relief from physiotherapy or analgetics. In the VN group physiotherapy, acupuncture and osteopathy relieved the headache in almost all patients. The combination of numbness and tenderness in the temporal area can also be linked to temporomandibular joint dysfunction with facial, head and neck pain [25–27]. Conversely, patients with migraine and trigeminal pain often display signs and symptoms in common with temporomandibular dysfunction [26]. Two patients in our study with tightened masticatory muscles were diagnosed to have temporomandibular joint dysfunction and they received treatment for it, with pain relief in one case. Paresthesias localised to the lip or the cheek area, and numbness and tingling, may affect the face also as a result of the trigeminal reflex activation or migraine [27]. Kentala [13] found trigeminal disturbances or facial paresthesia in 14% out of 107 patients with MD. Of these 107 patients 47% complained of cranial nerve symptoms that could not be objectively verified. There are many similarities between the occurrence of headache symptoms in cluster headaches and in Meniere’s disease [28]. The trigeminal innervation to the cochlea is known to be involved with endolymphatic hydrops. A significant reduction of trigeminal cochlear fibres in hydropic guinea pigs has been demonstrated. Neurotrophic factors are likely to play a role in the trigeminal sensory nerve degeneration in hydrops, too [16]. Thus, a denervation of trigeminal cochlear fibres with reduced cochlear blood supply could be a possible explanation for the headache symptoms. This hypothesis needs to be confirmed.
4.1. Treatment of headache Tension headache, as well as tightened mastication muscles due to temporomandibular joint syndrome, should be considered and treated specifically. Parker [5] and Rassekh [3] have reported an incidence of migraine in MD patient of 34 and 22%, respectively. Our study suggests a
S. Eklund / Auris Nasus Larynx 26 (1999) 427–433
much lower incidence of 6%. Thus, a routine trial with sumatriptan may not be justified. Amitriptylin, 50 mg dose [29], seems to be superior to placebo in chronic tension type headache. In those Meniere patients who suffer from persistent headache and fail to respond to analgesics, one should consider using antidepressants like amitriptylin which elevates the pain threshold.
5. Conclusions It is important to correctly diagnose headache in MD because specific treatment protocols can then be utilised. It is concluded that a disturbance in the sensory trigeminal system may be involved with headache in MD, manifesting as a chronic neuropathic disease. In some patients headache represents a continuum of both tension type headache and MD. The headache in MD can be severe and may need treatment, as in chronic neuropathic pain. Amitriptylin, 50 mg dose [29], seems to be a drug of choice in chronic tension type headache, and is the treatment of choice for neuropathic pain today [22]. We recommended this medication for chronic headache patients with MD. Further studies are needed to determine the pathogenesis of headache in MD.
References [1] Kayan A, Hood DJ. Neuro-otological manifestations of migraine. Brain 1984;107:1123–42. [2] Harker L, Rassekh C. Migraine equivalent as a cause of episodic vertigo. Laryngoscope 1988;98:160–4. [3] Rassekh C, Harker L. The prevalence of migraine in Meniere’s disease. Laryngoscope 1992;102:135–8. [4] Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States: relation to age, income, race, and other sociodemographic factors. J Am Med Assoc 1992;267:64–9. [5] Parker W. Meniere’s disease. Etiologic considerations. Arch Otol Head Neck Surg 1995;121:377–82. [6] Atkinson M. Migraine and Meniere’s disease. Arch Otolaryngol 1962;75:220–5. [7] Atkinson M. Meniere’s syndrome and migraine: observations on common causal relationships. Ann Intern Med 1943;18:797 – 808. [8] Hincliffe R. Headache and Meniere’s disease. Acta Otolaryngol 1963;63:384–90.
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[9] Dolowitz D. Meniere’s — an inner ear seizure. Laryngoscope 1979;89:67 – 77. [10] Gilbert GJ. Meniere’s syndrome and cluster vertigo. J Am Med Assoc 1965;191:87 – 90. [11] Johnson GD. Medical management of migraine-related dizziness and vertigo. Laryngoscope 1998;108(Suppl.):1– 28. [12] Evans KL, Baldwin DL, Bainbridge D, Morrison AW. Immune status in patients with Meniere’s disease. Arch Otorhinolaryngol 1988;245:287 – 92. [13] Kentala E. Characteristics of six otologic diseases involving vertigo. Am J Otol 1997;27:343 – 54. [14] Moskowitz MA. The neurobiology of vascular head pain. Ann Neurol 1984;16:157 – 68. [15] Vass Z, Shore SE, Nuttall AL, Miller JM. Direct evidence of trigeminal innervation of the cochlear blood vessels. Neuroscience 1998;84(2):559– 67. [16] Vass Z. Endolymphatic hydrops reduces retrograde labeling of trigeminal innervation to the cochlea. Exp Neurol 1998;151(2):241– 8. [17] Moskowitz MA. Basic mechanisms in vascular headache. Neurol Clin 1990;20:801 – 13. [18] Gobel H, Stolze H, Heinze A, Dworschak M, et al. Achtzehnmonatige langzeitanalyse der wirksamkeit, sicherkeit und vertraglichkeit von sumatriptan sc. in der akuttherapie von migraneanfallen. Nervenarzt 1996;67:471 – 83. [19] Pyykko¨ I, Ishizaki H, Kaasinen S, Aalto H. Intratympanic gentamicin in bilateral Meniere’s disease. Otolaryngol Head Neck Surg 1994;110:162 – 7. [20] Melzack R. McGill Pain Questionnaire: major properties and scoring methods. Pain 1975;1:277 – 99. [21] Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;7(Suppl.):1– 96. [22] Kalso E, Tasmuth T, Neuvonen P. Amitriptyline effectively relieves neuropathic pain following treatment of breast cancer. Pain 1996;64:293 – 302. [23] Cass SP, Amlerstjerne JKP, Yetiser S, Furman JM, et al. Migraine-related vestibulopathy. Ann Otol Rhinol Laryngol 1997;106:1282– 9. [24] Raskin NH. Acute and prophylactic treatment of migraine: practical approaches and pharmacologic rationale. Neurology 1993;43:39 – 42. [25] Bogduk N. The anatomical basis for cervicogenic headache. J Man Physiol Ther 1992;15:67 – 70. [26] Cooper BC, Cooper DL. Multidisciplinary approach to the differential diagnosis of facial, head and neck pain. J Prosthet Dent 1991;66:72 – 8. [27] Haley D, Shiffman E, Baker C, Belgrade M. The comparison of patients suffering from temporomandibular disorders and a general headache population. Headache 1993;33:210 – 3. [28] Gilbert GJ. Cluster headache and cluster vertigo. Headache 1970;9:195 – 200. [29] Diamond S, Medina JL. Chronic tension headache treated with amitriptyline. A double blind study. Headache 1982;22:96 – 8.
Headache in Meniere’s disease Susanna Eklund * Department of Otolaryngology, Uni6ersity Hospital of Helsinki, POB 220, FIN-00029, Helsinki, Finland Received 8 October 1998; received in revised form 17 January 1999; accepted 12 March 1999
Abstract Objecti6e: We examined headache in 86 patients with severe or moderately severe Meniere’s disease (MD) or with Meniere’s syndrome (MS) chosen for intratympanic gentamicin treatment. Forty-five patients with vestibular neuronitis (VN) served as a control group. Methods: In addition to a clinical examination, the patients filled out a questionnaire concerning their headache. Results: Altogether 60 MD patients (70%) and 26 VN patients (58%) reported headache. Headache was severe in 35 MD patients (58%), moderate in 16 patients (27%) and slight in nine MD patients (15%), and as a whole more severe than that of the VN patients (PB0.01). The MD patients exhibited significantly more occipital (P B0.005) and neck headache (PB 0.005) than the VN patients. Analgesics had been used by 82%, antidepressants by 35%, sumatriptan by 13% and carbamazepine and/or amitriptyline by 12% of the MD patients suffering from headache. Pain relief was reported as good by 27%, satisfactory by 60%, poor by 5% of the MD patients and 8% could not rate the pain relief. In this study migraine was diagnosed in 5 MD patients. Conclusion: It is concluded that MD is associated with headache that can be handicapping, and tricyclic antidepressants with pain alleviating medication is often needed to treat the headache in MD whereas sumatriptan did not alleviate the headache of the non-migraine patients. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Headache; Pressure; Meniere’s disease; Migraine; Vestibular neuronitis
1. Introduction A link between Meniere’s disease (MD) and headache was already reported by Prosper Meniere [1]. Various authors since have discussed the possible relationship between migraine and MD [1 – 11]. Both are episodic in nature, and often create an otoneurologic disorder consisting of vertigo spells, tinnitus, and alteration in hearing. The discrimination of peripheral labyrinthine disorders * Fax: + 353-0-4715094. E-mail address: [email protected] (S. Eklund)
and migraine has been difficult in several cases [2]. Rassekh [3] studied the difference in migraine prevalence between classic MD patients and those with only vestibular symptoms. He showed that the prevalence of migraine in classic MD was greater (22% of 46 patients) than the prevalence of migraine in the general population. Stewart et al. [4] studied the prevalence of migraine in the population of the United States and found that 18% of adult women and 6% of adult men have migraine. In a retrospective study of 85 patients with MD, Parker [5] found a higher incidence of migraine (34%) in MD than in the general popula-
0385-8146/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 9 9 ) 0 0 0 2 2 - X
428
S. Eklund / Auris Nasus Larynx 26 (1999) 427–433
tion. Parker [5] and Atkinson [6,7] stated that the symptoms in MD could result from vascular spasm of the inner ear vessels, similar to the presumed etiology in migraine. Hincliffe [8] reported headache in 75% of 42 patients with MD. Since the patients had scotomata, the headache was believed to be of migranous variety. Dolowitz [9] observed episodic headache in 83% of 125 patients with MD. He found that headache was a relatively independent symptom in vertigo patients, but associated with positional vertigo. The patients did not mention headache as a part of the disease, but when it was included in a questionnaire chart its presence became very obvious. Gilbert [10] reported cluster headaches in three patients with MD. He postulated that the same mechanism might precipitate the cluster headache and the MD in these patients. Johnson [11] treated 24 patients with a diagnosis of migraine-related dizziness with objective fluctuating hearing loss pharmacologically. When medical therapy was directed at the migraine using either benzodiazepins, tricyclic antidepressants, propranolol, selective serotonin reuptake inhibitors, amitriptyline or nortriptyline; the symptoms of migraine either completely resolved or improved substantially. In the study of Evans et al. [12], 31% of the patients with MD had a history of classical migraine headaches. In their study, 68% of the migraine patients had one or more autoantibodies present. Recently Kentala [13] reported that 64% of 107 patients with MD had headache and 47% had symptoms of paresthesia of the face and occiput. In objective evaluation their sensitivity appeared to be normal. Moskowitz [14] and Vass et al. [15,16] have demonstrated the existence of neural connections between the trigeminal nerve and the cerebral blood vessels defined as the trigeminovascular system. They hypothesised that neurogenic sterile inflammation of the intracranial and extracranial vasculature, mediated through the trigeminovascular reflex, is causing the headache [15 – 17]. The trigeminal innervation to the cochlea is known to be involved in endolymphatic hydrops [15], and may cause even the otoneurological symptoms in Meniere’s disease. Sumatriptan (5-HT-agonist) helps patients with migraine pain in 70 – 85% dur-
ing any moment of the attack [18], but no such reports are available on patients with headache in MD. The purpose of the study was to evaluate the incidence of headache and pressure in patients with severe and moderately severe MD. We also tried to explore the characteristics and localisation of the headache by reviewing 86 patients with MD treated with gentamicin. The use of painkillers and pain alleviation by different methods was queried. In open trial eight patients were treated with sumatriptan. As headache is a common ailment in the general population, we chose a group of patients with vestibular neuronitis (VN) as the control group.
2. Methods From a larger group of patients with MD in the study period 1987–1993, 89 patients with severe or moderately severe MD (criteria based on the American Academy of Otolaryngology-Head and Neck Surgery 1985) were selected for the present study. Also five patients with delayed hydrops were included in the study. Both MD patients and patients with delayed hydrops took part in a larger survey on the efficacy of gentamicin applied transtympanically [19]. A follow-up questionnaire concerning headache was sent to 91 surviving Meniere patients: 67 women and 24 men during September 1994 in order to chart out the characteristic features of headache and the treatments for it. Of the 91 surviving patients 86 (95%) replied to the questionnaire. The mean age of the patients was 50.9 years (range 19–74 years) and the mean duration of MD was 9.8 years (1–33 years). Subjects with occasional headache were classified into the non-headache group. Thus, eight patients who had headache only once or twice a year, and did not experience their headache as troublesome, were excluded from the headache group. The same questionnaire was administered to a control group of 60 patients with VN, and referred to the balance laboratory of the ENT department. In the questionnaire, the severity of the headache was classified as no, mild, moderate and
S. Eklund / Auris Nasus Larynx 26 (1999) 427–433
severe. Of the 60 patients, 45 (76%) answered the questionnaire. The mean age of these patients was 45.9 years (range 12 – 74 years). Four patients who had headache only once or twice a year, and whose headache was not troublesome, were classified in the non-headache group. We used a modified McGill Pain Questionnaire [20] to describe the severity of headache. The questionnaire contained 54 different words in the major classes—sensory, affective and evaluative. The words were in groups containing three to six similar words characterising pain. The patients were asked to select from each group the words that characterised their symptom best. Also factors that provoke headache were asked. The medical records of the patients were reviewed in detail to find a connection between other possible causes of headache and medication. The patients were asked if they still had persistent headache, and what had been done to treat this pain. The detri-
Fig. 1. Area of the head pain in 60 patients with MD.
Fig. 2. Extent of headache of the 60 patients with MD.
429
mental effect of headache on the subject’s performance at work was also asked. Diagnosis of migraine was based on the International Classification Committee of the Headache Society (ICCIHS) [21].
2.1. Statistics The significance of the treatment on headache and various factors determining the severity of MD was sought in linear regression analysis. In searching for risk factors, a logistic regression analysis was performed. The x 2-test and the Fischer’s exact test were used to analyse the headache in the groups of MD and of VN and pain relief.
3. Results
3.1. MD patients Altogether 60 patients out of 86 with MD (70%) had headache. Of these 60 patients 46 (77%) had persistent headache and 15 (23%) temporary headache. The headache was felt mainly in the forehead (61%), the occiput (58%), and around the neck (38%) (Fig. 1). The headache was severe in 35 (58%) patients, moderate in 16 (27%) and slight in eight (15%) patients (Fig. 2). Only one of the patients had to change jobs because of headache, but 33 (56%) felt that their job performance or household tasks suffered because of their headache. In the McGill Pain Questionnaire, the headache was described mostly as disturbing sleep, onesided, disabling and numb (Table 1). Headache was associated with pressure in the head or postauricular region in 44 (73%)of the MD patients, with tinnitus in 41 (68%), with visual symptoms in 29 (48%), with nausea in 29 (48%), with vertigo in 26 (43%). Headache occurred daily in 16 (27%) of the MD patients, weekly in 18 (30%), monthly in 15 (25%) and less frequently in eight (13%) of the patients with MD. Altogether 26 (58%) of the patients with VN had headache. 42% of these patients had persistent headache and 58% temporary headache. The
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Table 1 Sensory and affective characteristics of the headache in 26 VN and 60 MD patients Type of headache (sensation)
% VN
% MD
Type of headache (affectiveness)
% VN
% MD
Pulsating Pounding Through Wavy One-sided Deep Stabbing Numb Strucking
47 10 27 10 43 20 13 7 13
13 17 30 25 37 25 21 36 11
Psychic Epileptic Annoying Sore Nauseating Disabiliting work Wearing Awakening Heavy
30 3 69 21 30 7 37 20 18
36 14 31 13 16 32 30 42 22
headache was mainly frontal (57%), and around the eyes (30%) (Fig. 3). The headache associated with nausea in 35%, pressure in the head or postauricular region in 31%, with visual symptoms in 31% and with vertigo in 19%. The headache was severe only in two patients (8%) (Fig. 4). The headache occurred daily in 4%, weekly in 40%, monthly in 46% and less frequently in 10% of the patients. The patients picked out 17 words characterising their headache from the questionnaire. The pain was described mainly as annoying, pulsating, onesided and wearing (Table 1). Eight percent of the patients had to modify their jobs because the headache was so incapacitating.
0.05). There was no statistical difference between the two groups in the sensory, affective or evaluative words characterising the pain evaluated with the McGill Pain Questionnaire.
3.2. Difference between the groups The patients with MD had more daily headache (PB0.005), they exhibited significantly more occipital pain (P B 0.001), neck muscle (PB 0.005) and ear pain (P B0.05) than the patients with VN. The headache caused difficulties in the sleep rhythm more often in the Meniere group (P B0.05), as well as work disability, than in the control patients (P B 0.005). Headache was related to pressure, tinnitus, nausea and vertigo only in patients with MD (P B 0.05). The severity of the headache caused more problems for the patients with MD than for the patients with VN (P B0.01). In the MD physical efforts such as bowing, were a statistically significant provoking factor for headache (P B
Fig. 3. Area of the head pain in 26 patients with vestibular neuronitis (VN).
Fig. 4. Extent of headache in 26 patients with vestibular neuronitis (VN).
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Fig. 5. Experient of pain in 60 patients with MD.
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tory drugs for headache, 21 (35%) had used antidepressants, and seven (12%) of the patients amitriptyline and/or carbamazepine. The latter two treatments constitute the treatment of choice for neuropathic pain today [22]. Of all the headache patients, 16 (27%) considered the pain relief was good (Fig. 5). Only 4% had tried to alleviate their pain with strong analgesics, 7% with physiotherapy, 4% with anxiolytics, and 21% with acupuncture. Sumatriptan was given in an open trial to eight patients without response. Acupuncture, physiotherapy and anxiolytics gave some help to eight patients, but worsened the headache of one patient. Of the 26 patients with VN who had headache, 21 (81%) had used non-steroidal anti-inflammatory drugs for headache and one patient had used antidepressants. Thirty-one percent had tried to alleviate their pain with physiotherapy, two patients with acupuncture and one patient with osteopathy. Of the VN patients 42% considered the pain relief was good (Fig. 6).
4. Discussion Fig. 6. Experience of pain relief in 26 VN patients treated with analgesics.
3.3. Risk factors for headache in MD A significant correlation was found between persistent headache and working capacity (r = 0.663, PB 0.001). A logistic regression analysis was tried to search for risk factors predicting severe and persistent headache. The following models were included in the model: sex, ELS surgery, unsteadiness, severity of rotatory attacks, outcome of caloric responses, severity of Tumarkin otolitic attacks, pressure in the ear, tinnitus, and overall handicap. With the maximum likelihood method, no factor as such predicted persistent headache.
3.4. Therapy Of the 60 Meniere patients who had headache, 49 (82%) had used non-steroidal anti-inflamma-
The high response rate of 95% to the questionnaire suggests the extent of problem with headache treatment among the Meniere patients. The incidence of headache in 70% and the persistent headache in 77% of these headache patients prompted the patients to answer. In our study, 43% of the patients experienced vertigo associated with headache, which is significantly more than in the study of patients with migraine-related vertigo [11] (9%). This finding may reflect the selection of patients with more severe MD in our study. It may also indicate that the same disturbance in the sensory trigeminal system may trigger vertigo and headache in MD. The previous contenders [3,5–8] for a high prevalence of migrainous aetiology did not receive support in the present study, as the incidence of migraine was only 6% that is comparable to 8% in the general population [21]. Sumatriptan (a 5-HTagonist) has proven effective in aborting migraine headaches [18]. In an open trial, eight patients in
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this study were given sumatriptan without response. Our results confirm the study by Cass et al. [23] in which they suggest that the relationship between migraine and MD seems to be a matter of chance than a positive association. Headache was associated with a feeling of pressure in the head or postauricular region in 72% of the patients. The persistent headache, despite the use of painkillers, in 77% of the patients is typical of neuropathic pain. In neuropathic pain relief, antidepressants and/or amitriptyline constitute the treatment of choice today [22] as they reduce the frequency and severity of headache in migraine patients [11]. It has been suggested that the antimigraine effect of amitriptyline is mediated through the stabilisation of serotoninergic transmission [24]. It was rather disappointing to find out that only 12% of the patients with headache had received amitriptyline and/or carbamazepine. A difference was found in the severity of headache between the patient groups. Severe headache was present in MD in 58%, whereas in the VN group in only 8% of the patients. It is not possible to compare this with other studies, because they did not grade the severity of headache with other patient groups. The short duration of effectiveness of analgesics was reported more often by Meniere patients, too. The findings thus confirm earlier observations that in the disease entity of MD, headache is one of the significant components and should thus be included in the associated symptom list with the same weight as, for example, pressure in the ear. Headache occurred daily in 27% of the MD patients, and in only 4% of the control group. The ability to continue working was not reduced in the control group, while for the MD patients headache was a disabling factor. Tension headache is a common type of headache caused by tension in the receptive fields from the three cervical nerves. The muscles, joints and ligaments have been shown to be capable of causing headache [25]. Although seven of the 11 MD patients with self-reported neck muscle contraction had tried to alleviate pain with acupuncture, physiotherapy or anxiolytics, the headache had persisted in all of them. The pain type in four of these MD patients was deep, penetrating,
sharp, or pounding, and accompanied by numbness and tenderness in the pain area. Although the description and localisation of the pain point to tension headache in these patients, they had no relief from physiotherapy or analgetics. In the VN group physiotherapy, acupuncture and osteopathy relieved the headache in almost all patients. The combination of numbness and tenderness in the temporal area can also be linked to temporomandibular joint dysfunction with facial, head and neck pain [25–27]. Conversely, patients with migraine and trigeminal pain often display signs and symptoms in common with temporomandibular dysfunction [26]. Two patients in our study with tightened masticatory muscles were diagnosed to have temporomandibular joint dysfunction and they received treatment for it, with pain relief in one case. Paresthesias localised to the lip or the cheek area, and numbness and tingling, may affect the face also as a result of the trigeminal reflex activation or migraine [27]. Kentala [13] found trigeminal disturbances or facial paresthesia in 14% out of 107 patients with MD. Of these 107 patients 47% complained of cranial nerve symptoms that could not be objectively verified. There are many similarities between the occurrence of headache symptoms in cluster headaches and in Meniere’s disease [28]. The trigeminal innervation to the cochlea is known to be involved with endolymphatic hydrops. A significant reduction of trigeminal cochlear fibres in hydropic guinea pigs has been demonstrated. Neurotrophic factors are likely to play a role in the trigeminal sensory nerve degeneration in hydrops, too [16]. Thus, a denervation of trigeminal cochlear fibres with reduced cochlear blood supply could be a possible explanation for the headache symptoms. This hypothesis needs to be confirmed.
4.1. Treatment of headache Tension headache, as well as tightened mastication muscles due to temporomandibular joint syndrome, should be considered and treated specifically. Parker [5] and Rassekh [3] have reported an incidence of migraine in MD patient of 34 and 22%, respectively. Our study suggests a
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much lower incidence of 6%. Thus, a routine trial with sumatriptan may not be justified. Amitriptylin, 50 mg dose [29], seems to be superior to placebo in chronic tension type headache. In those Meniere patients who suffer from persistent headache and fail to respond to analgesics, one should consider using antidepressants like amitriptylin which elevates the pain threshold.
5. Conclusions It is important to correctly diagnose headache in MD because specific treatment protocols can then be utilised. It is concluded that a disturbance in the sensory trigeminal system may be involved with headache in MD, manifesting as a chronic neuropathic disease. In some patients headache represents a continuum of both tension type headache and MD. The headache in MD can be severe and may need treatment, as in chronic neuropathic pain. Amitriptylin, 50 mg dose [29], seems to be a drug of choice in chronic tension type headache, and is the treatment of choice for neuropathic pain today [22]. We recommended this medication for chronic headache patients with MD. Further studies are needed to determine the pathogenesis of headache in MD.
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