Headache Medicine 2021, 12(4):323-327 p-ISSN 2178-7468, e-ISSN 2763-6178

323

ASAA

DOI: 10.48208/HeadacheMed.2021.53

Headache Medicine

Original

Hyperacusis in migraine: pilot project

Bruna Colomera Maistro , Ana Clara Oliver Machado , Beatriz Bagatim Bossa , Valéria Aparecida Bello ,

Regina Célia Poli Frederico , Aline Vitali da Silva

Medical School, Pontifícia Universidade Católica do Paraná (PUC-PR), Londrina, Paraná, Brazil

Abstract

Introduction

Patients with migraine may report hearing disorders, such as hyperacusis and pho-

nophobia.

Objectives

To evaluate the prevalence and predictors of hyperacusis in patients with migraine.

Methods

A prospective case-control study was carried out at the specialties outpatient clinic of PUC-

-PR, campus Londrina. The present study included adult patients diagnosed with migraine.

Study participants completed a structured interview on demographic and anthropometric

data and clinical characteristics of migraine. They also completed validated questionnaires

on depression (BDI), anxiety (STAI2), disability (MIDAS), allodynia (ASC-12), and the

hyperacusis questionnaire. Two hundred seventy-six patients with migraine answered the

questionnaires. The participant was considered to have hyperacusis when the score was

greater than or equal to 22 points.

Results

We evaluated 276 individuals with migraine who answered the questionnaires, 162

without hyperacusis, and 114 with hyperacusis. Regarding the univariate analyses, epi-

sodic migraine (p=0.001; OR=2.28), phonophobia (p=0.017; OR=2.56), osmophobia

(p<0.001; OR=2.97) and allodynia (p<0.010; OR= 2.91) showed signicant results in

patients with hyperacusis. Patients without a trace of anxiety (p=0.007; OR=10.53) and

absence of depression (p=0.002; OR=2.89) were also related to hyperacusis.

As for multivariate analyses, patient characteristics that were signicantly associa-

ted with hyperacusis include episodic migraine (p=0.019; OR=2.029), osmophobia

(p=0.022; OR=2.214), and mild and moderate migraine-related disability. (p=0.022;

OR=2.158).

Conclusions

Patients with episodic migraine who have osmophobia and mild to moderate disability

related to this neurological disease are twice as likely to have hyperacusis, being consi-

dered important predictors of such hearing disorder. The presence or absence of aura

and photophobia did not present results with relevant statistical differences.

Bruna Colomera Maistro

maistrobruna@gmail.com

Edited by:

Marcelo Moraes Valença

Keywords:

Migraine

Hyperacusis

Phonophobia

Received: January, 15 2022

Accepted: February, 15 2022

324

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Maistro BC, Machado ACO, Bossa BB, Bello VA, Frederico RCP, Silva AV

Hyperacusis in migraine: pilot project

Introduction

igraine is a brain disorder that presents neurological

symptoms with headache attacks. The pain may be uni-

lateral, moderate to severe in intensity, associated with nausea,

vomiting, photophobia and phonophobia. There are even

cases of sensory, motor, and emotional impairment. In addi-

tion, it commonly has a family history.

Besides, migraine has

several distinct classications. Among these, the most relevant

are migraine with aura (before called as classic migraine), that

is usually preceded by visual, sensory, or language symptoms.

According to the International Headache Society, the

following criteria are used to diagnosemigraine without

aura.

A. At least 5 headache attacks in a lifetime;

B. Episodes lasting 4 to 72 hours when untreated or ineffectively

treated;

C. Headache with at least two of the following characteristics:

unilateral; pulsatile; moderate to severe pain; and worsening

of the condition with day-to-day activities or impossibility to

perform such activities due to intense pain;

D. Headache accompanied by at least one of the following:

nausea and/or vomiting; photophobia and phonophobia.

Balance disturbances such as rational vertigo, positional vertigo,

dizziness, and others have also been related during headache

attacks.

3-12

Thus, studies indicate that patients diagnosed with

migraine who have experienced kinetosis at some point in their

lives seem to be more susceptible to migraine attacks.

3,12-17

In addition, this type of headache may be associated to the

development of hearing disorders such as hyperacusis and

phonophobia.

Hyperacusis is an unpleasant sensation

caused by exposure to sound, due to a reduction in one's

tolerance.

It is characterized by increased sound sensation

in the auditory pathway and loss of the dynamic range of the

ear.

In the case of phonophobia, only certain sounds are

uncomfortable, while others can be comfortable even at high

intensities.

The primary difference between migraine with aura and

migraine associated with auditory-vestibular dysfunction is

the duration of the headache. In cases of migraine associated

with auditory vestibular dysfunction, symptoms may last for

hours, days, or weeks, while the symptoms of migraine with

aura last from seconds to 1 hour.

Another very characteristic symptom of migraine associated

with auditory-vestibular dysfunction is motion intolerance,

like kinetosis. Patients with such dysfunction report vertigo

whenever their head is in the trigger position.

Cases of

visual vertigo, which are usually induced by screens and

specic illumination, are also characteristic of the picture.

Hyperacusis can be diagnosed by Loudness Discomfort Level

(LDL)

, which will be responsible for evaluating the degree

of discomfort of a sound at each frequency.

The test starts

by presenting the sound from 50

or 60 dB NA, increasing

to 5dB with time, with stimulus onset at a frequency of 500

Hz amplifying to 1,000, 2,000 or 4,000 Hz

, and duration

of two seconds each stimulus, with a one-second interval

between stimuli.

The patient is instructed to notify the exact

moment the sound becomes uncomfortable.

The reference values for LDL were analyzed in two studies

of normal-hearing individuals without complaints of auditory

hypersensitivity, both studies obtained average results of the

level of discomfort from 100 dB NA.

27,28

In another study,

with the stimulus frequency ranging from 500 to 8,000 Hz,

the reference value of LDL for normal hearing was 86 to 98

dB NA.

In the study done in patients with hyperacusis, the LDL

reference values ranged between 50 and 90 dB HL. To

classify the degree of hyperacusis, the Johnson Hyperacusis

Dynamic Range Quotient (JHQ) which is given by subtracting

the LDL by the pure tone threshold (AL), this result is still

divided by the frequencies used in the study, to obtain the

JHQ, it is still necessary to add the dynamic ranges, divided

by the number of frequencies evaluated. The scale of the

degree of hyperacusis, from the JHQ, can be mild (75-90

dB), moderate (50-74 dB), severe (30-49 dB) or profound

(0-29 dB).

Also in the same study, a questionnaire was used to

differentiate between patients who have hyperacusis and

those who do not. The questionnaire is divided into three

parts. The rst part consists of questions about hypersensitivity

to sound, whether it is present, the degree and types of sound

that cause discomfort to the individual, triggers, and reactions

to hearing hypersensitivity. The second part addresses

questions about hearing loss and exposure to intense sound.

The third part is questions about personal background and

existing medical conditions, including migraine.

Two other studies used a unique questionnaire for patients with

hyperacusis, which assess which sounds are uncomfortable

and what the individual's reaction to uncomfortable sounds.

The sounds questioned in the studies are: loud music,

horns, people talking loudly, trafc noise, slamming doors,

sudden and loud sounds, dripping faucet, restaurant noise,

325

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Maistro BC, Machado ACO, Bossa BB, Bello VA, Frederico RCP, Silva AV

Hyperacusis in migraine: pilot project

doorbell, police siren, airplane, plastic bag noise, blender,

telephone ringing, loud laughter, airplane noises, barking

dogs, rearms, children crying, television at normal volume,

simultaneous conversation, and music at normal volume.

The behavioral reactions present in the questionnaire are

irritation, anxiety, need to leave the sound, tinnitus, tension,

disorientation, aggressiveness, pain, dizziness, anger,

shock, panic, fear, momentary stress, loss of concentration

and headache.

29,30

Method

After submission and approval of the research by the

Research Ethics Committee (no 3.029.972), a prospective

case-control study was carried out at the specialties

outpatient clinic of PUC-PR, campus Londrina. The present

study included patients diagnosed with migraine, 18 years

old or older and younger than 60 years old. Study participants

completed a structured interview on demographic and

anthropometric data and clinical characteristics of migraine.

They also completed validated questionnaires on depression

(BDI), anxiety (STAI2), disability (MIDAS), allodynia (ASC-12),

and the hyperacusis questionnaire. The questionnaires were

answered by 276 patients with migraine. The hyperacusis

questionnaire was composed of 14 questions to classify the

patients who have hyperacusis and those who do not have

hyperacusis. Each answer marked "no" corresponds to 0

points; "yes, a little" corresponds to 1 point; "yes, fairly"

corresponds to 2 points; and "yes, a lot" corresponds to 3

points. The participant was considered to have hyperacusis

when the score was greater than or equal to 22 points. In the

statistical analysis it was considered the signicance value

p<0.05.

Results and Discussion

We evaluated 276 individuals with migraine who answered

the applicable questionnaires, 162 without hyperacusis and

114 with hyperacusis. Results of univariate and multivariate

analyzes were obtained, relating patients with hyperacusis

according to age, sex, ethnicity, BMI, type of migraine,

presence of aura, phonophobia, photophobia, osmophobia,

allodynia, anxiety, depression and disability (Table 1).

Table 1. Comparative analysis of individuals without hyperacusis and with hyperacusis diagnosed with migraine.

Without hyperacusis N= 162 With hyperacusis N=114 Univaried Analysis Multivariate Analysis

Median

Age (median)

30 33 0.614 0.994

n (%) n (%)

Sex

Male 28 1 7. 3 0 11 9.60 0.073 1.96 0.555 1.296

Female 134 82.70 103 90.40

Ethnicity

Caucasian 135 83.30 92 80.70 0.573 1.2 0.620 0.83

Non caucasian 27 16.70 22 19.30

BMI_dico_29_30

Without obesity (BMI<30) 135 83.90 93 81.60 0.622 1.17 0.637 0.829

Obesity (BMI≥30) 26 16.10 21 18.40

Migraine Type

Episodic 113 70.60 58 51.30 0.001* 2.28 0.019 2.029

Chronic 47 29.40 55 48.70

Migraine with aura

No 103 63.60 67 58.80 0.419 1.22 0.935 1.025

Yes 59 36.40 47 41.20

Phonophobia

No 29 18.00 9 7. 90 0.017* 2.56 0.090 2.221

Yes 132 82.00 105 92.10

Photophobia

No 10 6.20 7 6.10 0.981 1.01 0.482 0.643

Yes 151 93.80 107 93.90

Osmophobia

No 62 38.30 19 17.30% <0.001* 2.97 0.022 2.214

Yes 100 61.70 91 82.70%

ASC12_dico

Mild or none (0-5) 97 60.20 39 34.20% <0.001* 2.91 0.056 1.773

Moderate to severe (≥6) 64 39.80 75 65.80%

Anxiety-Trait

Without anxiety 161 99.40 107 93.90% 0.007*,b 10.53 0.224 4.179

With anxiety 1 0.60 7 6.10%

Depression

Without depression 147 90.70 88 77.20% 0.002* 2.89 0.153 1.868

With depression 15 9.30 26 22.80%

MIDAS_dico10_11

Mild disability or none 143 90.50 88 77.20% 0.002* 2.81 0.022 2.518

Moderate to severe disability 15 9.50 26 22.80%

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Maistro BC, Machado ACO, Bossa BB, Bello VA, Frederico RCP, Silva AV

Hyperacusis in migraine: pilot project

Regarding the univariate analyses, episodic migraine

(p=0.001; OR=2.28), phonophobia (p=0.017; OR=2.56),

osmophobia (p<0.001; OR=2.97) and allodynia (p<0.010;

OR= 2.91) showed signicant results in patients with

hyperacusis. Patients without trace of anxiety (p=0.007;

OR=10.53) and absence of depression (p=0.002;

OR=2.89) were also related to hyperacusis.

As for multivariate analyses, patient characteristics that

were signicantly associated with hyperacusis include

episodic migraine (p=0.019; OR=2.029), osmophobia

(p=0.022; OR=2.214), and mild and moderate migraine-

related disability. (p=0.022; OR=2.158).

Conclusion

Patients with episodic migraine who have osmophobia

and mild to moderate disability related to this neurological

disease are twice as likely to have hyperacusis, being

considered important predictors of such hearing disorder.

The presence or absence of aura and photophobia did

not present results with relevant statistical differences

(p>0.05).

Author’s contribution: BCM, ACOM, BBB, manuscript

writing; manuscrip design; analysis of data; review;

approval of the nal version. VAB, RCPF, AVS study

conception and design; manuscript e review; approval of

the nal version.

Financing: there was no funding.

Conflict of interest: the authors declare is not conict of

interest.

Bruna Colomera Maistro

https://orcid.org/0000-0001-8360-8801

Ana Clara Oliver Machado

https://orcid.org/0000-0001-6469-2462

Beatriz Bagatim Bossa

https://orcid.org/0000-0001-5538-1689

Valéria Aparecida Bello

https://orcid.org/0000-0001-7919-6218

Regina Célia Poli Frederico

https://orcid.org/0000-0003-4631-4606

Aline Vitali da Silva

https://orcid.org/0000-0001-7797-9227

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