Jason mentioned something to me that more often than not, would have seemed not too important. However, this time, it was different. He made an off-handed comment that whenever his sinus pain and pressure gets worse, his right ear ringing (tinnitus) also worsened. Typically I would have noted this comment down in my medical records and moved on, but this time, it was a major revelation.
Conventional wisdom for medical education
We tell medical students and residents that learning doesn’t stop after you finish residency. The traditional advice is that you should continue learning, adding to the basic fund of knowledge that was achieved during your schooling and training years. These activities involve keeping up with the latest journals, going to conferences, seminars and other educational activities, and for those in academia, do research and publish.
But the most important source of learning is from the patient sitting in front of you. He or she is your most important teacher, but only if you truly listen. But listening alone won’t make any difference if you’re not constantly reading, along with all the other activities listed above.
Migraines are not just headaches
In this particular case, a number of concepts that I had learned over the years came together to make total sense when Jason told me about his ear ringing and sinus pain. The first is that migraines can happen in any area of the body that has nerve endings, which is everywhere.
If you have a stomach migraine (like many young children), you’ll have an upset stomach, nausea, diarrhea or constipation. A sinus migraine will present with sinus pain and pressure, nasal congestion, post-nasal drip, and headaches. An inner ear migraine may give you hearing loss, dizziness, ringing, or balance problems.
Any time your sensory nerve endings are irritated, you feel their respective symptoms. This basic concept was first introduced to me by Dr. David Buchholz, a Johns Hopkins neurologist, and author of the book “Heal Your Headache.” Even within ENT journals and textbooks, the concept of migraine variants such as sinus migraines and vestibular (inner ear) migraines have been proposed, but not widely applied.
A migraine has many causes, including stress, certain foods (red wine, aged cheeses, chocolates, and MSG), weather changes, and especially sleep deprivation. Having a sleep-breathing disorder (such as obstructive sleep apnea or upper airway resistance syndrome) can be a major trigger for migraines anywhere in your body.
Sinus infections may not be an infection
After reading Dr. Buchholz’s book, I came across a study in a headache journal showing that the vast majority of people people with sinus pain, pressure and “recurrent infections” were actually having a migraine attack. Just afterwards, I saw a middle-aged woman who was suffering from severe recurrent sinus infections, who had been given multiple courses of antibiotics, with only temporary relief. Her condition was classic for a sinus migraine, but she was reluctant to accept this diagnosis. As a compromise, I convinced her to try a migraine aborting medication called Imitrex. She ended up taking one dose during an attack, and was surprised to find that it got rid of her sinus “infection” almost instantly. With dietary and lifestyle modifications, she suffered significantly less sinus infections, not needing any more antibiotics.
Dizziness from a migraine?
One simple personal application can be described as follows: 2 weeks after our second son was born, I developed classic BPV, or benign positional vertigo. I had the classic symptoms: Every time, I turned my head to one side, the room would spin for about 30 seconds. I did the diagnostic test called the Dix-Hallpike maneuver, and the therapeutic Epley maneuver, which helped, but only temporarily. The problem was that I had none of the classic risk factors such as infection or head trauma. The only variable was major sleep deprivation, something that’s not high on the list of predisposing risk factors for BPV.
The current explanation for BPV is that small stones come off the paired sensors and as it drops to the bottom of the semi-circular canal on one side, the shift in fluid tugs on the swaying sensor, sending extra signals to your brain, making you think that your head is still moving. Once the stone stops moving, the dizziness goes away. After adjusting my sleep schedule a few weeks later, the episodes resolved completely. My feeling is that everyone has inner ear crystals, with many falling off harmlessly. However, if your inner ear sensors are extra sensitive, then normal stones that fall off will cause an exaggerated signal to be transmitted to one side of the brain. I once did a blog post about my experience with BPV, and you can see that there are lots of other people with similar experiences. One of recurrent themes is that BPV usually gets better with better quality sleep. There are reports of vertigo related with migraines, but this concept is not being used in more practical ways.
Chicken or the egg?
Jason’s comment about his ear ringing getting better when his sinus problems improved only connected the dots about how to better approach patients with tinnitus. Oftentimes, patients with ringing can be challenging to treat. In fact, I know of one otologist who refused to see patients with tinnitus after his mentor was shot dead by a patient with severe tinnitus. Although there are many proposed treatment options, none are too satisfying. One common recommendation is to give an antidepressant.
We now know that poor sleep quality or quantity due to any reason can aggravate depression and migraines. This brings up the chicken or the egg question: Does depression cause tinnitus, tinnitus cause depression, or does poor sleep cause both? My biased opinion is to suggest the latter.
Mundane statements like what Jason said are but one of many examples where various dots are connected, leading to a “forest from the trees” approach to health and wellness. For example, women were telling me that they suffered from a sore throat just before their periods. Their doctors looked at them like they were crazy. But looking at this from a sleep-breathing paradigm, we know that as progesterone drops just before a woman’s period, the tongue muscle relaxes, leading to more obstructed breathing and more acid reflux. My blog post on this topic has generated the highest number of comments ever.
The importance of listening to patients
Granted, I may be entering the therapy world by analyzing every word that’s uttered by my patients, but if you truly listen and take the time to understand what they are saying, it’s much easier to help patients feel better by breathing and sleeping better. Unfortunately, with limited face-to-face times between physicians and patients these days, this kind of detective work and trouble shooting can be very challenging. Despite these obstacles, it behooves us physicians to fight the trend to see the patient quickly and order more tests to make a diagnosis. It’s also important for patients never to hold back information that may seem too trivial or not relevant. Occasionally, your comment may make all the difference in making the right diagnosis.