Can tinnitus (ringing in the ears) cause headaches?

Tinnitus and Headaches: Understanding the Relationship

Tinnitus can be associated with headaches, with evidence suggesting a bidirectional relationship between these conditions rather than a purely coincidental occurrence. 1, 2

Relationship Between Tinnitus and Headaches

• Patients with tinnitus have a significantly higher prevalence of headaches compared to the general population, with studies showing headaches occur in approximately 26% of tinnitus patients, increasing to 40% in those with severe tinnitus 1
• There is a significant relationship between tinnitus laterality and headache laterality, with many patients experiencing both symptoms on the same side of the head 2, 3
• Fluctuations in symptom severity of tinnitus and headache are often interrelated, suggesting common underlying pathophysiological mechanisms 2

Prevalence and Impact

• In clinical studies, approximately 49.3% of tinnitus patients were diagnosed with headache, most commonly tension-type headache or migraine 3
• Tinnitus patients with comorbid headaches typically show higher scores on tinnitus questionnaires, indicating greater distress and impact on quality of life 4
• The relationship appears strongest with specific headache types, particularly migraine and cluster headaches 4

Clinical Characteristics of Patients with Both Conditions

• Patients with both tinnitus and headaches are more likely to be:
  • Younger in age 3
  • Female 3
  • Experiencing bilateral tinnitus 3
  • Suffering from vertigo 3, 4
  • Experiencing depression or anxiety 3, 4
  • Reporting other pain syndromes (neck pain, temporomandibular disorders) 4

Assessment Considerations

• When evaluating patients with tinnitus, clinicians should inquire about headache symptoms, as the presence of headaches may indicate a more complex clinical picture 5, 3
• During assessment, it's important to determine if the patient experiences:
  • Pulsatile or non-pulsatile tinnitus 5
  • Unilateral or bilateral symptoms 3
  • Associated symptoms such as vertigo, hearing loss, or fullness in the ear 5
  • Fluctuations in tinnitus that correlate with headache episodes 2

Diagnostic Approach

• The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) guidelines recommend a targeted history and clinical examination as the initial evaluation for tinnitus patients 5
• When tinnitus is accompanied by headache, clinicians should consider:
  • Comprehensive audiological examination, especially with unilateral persistent tinnitus 5
  • Potential need for imaging studies if tinnitus is pulsatile or associated with focal neurological abnormalities 5
  • Evaluation for Ménière's disease, which can present with both tinnitus and headache-like symptoms 5

Treatment Implications

• Management approaches should consider both conditions:
  • Treatment of one condition may affect the other, as seen in cases where botulinum toxin treatment for chronic migraine also improved tinnitus symptoms 6
  • Addressing underlying factors like stress, anxiety, and neck pain may benefit both conditions 4
  • Patients with both conditions often require more comprehensive management approaches due to their greater overall symptom burden 1, 4

Important Caveats

• Not all headaches associated with tinnitus indicate serious underlying pathology; however, certain warning signs warrant further investigation:
  • New-onset severe headache with tinnitus 5
  • Pulsatile tinnitus, which may indicate vascular abnormalities 5
  • Tinnitus with focal neurological deficits 5
• Patients with tinnitus and severe anxiety or depression require prompt identification and intervention, as suicide has been reported in patients with tinnitus who have coexisting psychiatric illness 5