Can Migraines Be Secondary to Tinnitus?
No, migraines are not secondary to tinnitus—the relationship flows in the opposite direction, with migraine potentially causing or exacerbating tinnitus through shared central nervous system pathways. 1, 2
Understanding the Directional Relationship
The clinical evidence demonstrates that migraine acts as a primary disorder that can trigger or worsen tinnitus, not the reverse:
Migraine can cause auditory symptoms including tinnitus through trigeminal nerve activation of the auditory cortex during migraine attacks, resulting in tinnitus fluctuation in susceptible patients 2
Up to 45% of tinnitus patients concomitantly suffer from migraine, suggesting migraine as a contributing factor to tinnitus rather than tinnitus causing migraine 2
Vestibular migraine is recognized as a distinct migraine syndrome that includes auditory symptoms (tinnitus and hearing loss) alongside vestibular symptoms, with these auditory features described before, during, or after migraine attacks 1
Shared Pathophysiological Mechanisms
Both conditions stem from central nervous system disturbances rather than one causing the other:
Trigeminal nerve pathway involvement modulates sound sensitivity by activating the auditory cortex during migraine attacks, which can result in tinnitus perception 2
Increased vascular permeability in both the brain and inner ear from trigeminal nerve inflammation produces both headache and auditory symptoms simultaneously 2
Aberrant cerebellar-cortical connectivity has been demonstrated in patients with migraine comorbid with tinnitus, showing decreased cerebellar network connectivity with executive control networks and visual networks 3
Reduced cerebral blood flow in the auditory and prefrontal cortex occurs in chronic tinnitus patients, with migraine facilitating further CBF decreases 4
Clinical Differentiation from Ménière's Disease
When evaluating patients with both tinnitus and headache, clinicians must distinguish migraine-related tinnitus from Ménière's disease:
Vestibular migraine typically presents with attacks lasting 5 minutes to 72 hours, with hearing loss that is mild or absent and stable over time 1
Motion intolerance and light sensitivities in migraine help differentiate it from Ménière's disease, which presents with fluctuating hearing loss and episodic vertigo with aural fullness 1
Clinicians should determine if patients meet diagnostic criteria for vestibular migraine when assessing for Ménière's disease, as VM is a common cause of dizziness that can closely mimic MD 1
Shared Symptom Triggers
The bidirectional exacerbation occurs through common triggers rather than direct causation:
Stress, sleep disturbances, and dietary factors serve as triggers for both tinnitus and migraine, explaining why patients experience worsening of both conditions simultaneously 2
Treatment of migraine can improve tinnitus, as demonstrated by studies showing botulinum toxin injections for chronic migraine abolished or significantly reduced tinnitus in patients with both conditions 5
Clinical Implications for Management
Understanding this relationship guides treatment strategy:
Treating the underlying migraine may improve associated tinnitus symptoms, with intramuscular onabotulinumtoxin A injections to craniocervical muscles showing tinnitus attenuation of 70-100% in chronic migraine patients 5
Migraine therapies show promising results for treatment of tinnitus in patients with comorbid conditions, supporting the concept that migraine drives tinnitus rather than vice versa 2
The emotional impact should not be underestimated, as patients struggle with ongoing vertigo attacks and incapacitating tinnitus, requiring clinician assistance with reasonable treatment expectations 1
Common Pitfall to Avoid
Do not assume tinnitus is causing headaches when evaluating patients with both symptoms—instead, systematically assess for migraine using ICHD-3 criteria (at least 5 attacks lasting 4-72 hours with unilateral, pulsating, moderate-to-severe headache aggravated by activity, plus nausea/vomiting or photophobia/phonophobia) 1