MD Review of Tinnitus and Allergies

As a tinnitus specialist and ENT doctor, I get a lot of questions about the relationship between allergies and tinnitus. Here, I cover these important topics:

• Can allergies make your ears ring?
• Can Eustachian tube dysfunction cause tinnitus?
• What is aural fullness?
• Migraine, Allergies, and Ear Ringing
• Treatments for Allergy-Induced Tinnitus

Intro to Allergies and Tinnitus

Allergies are related to tinnitus through two possible mechanisms: Eustachian tube dysfunction and atypical migraine. The direct cause of tinnitus is inner ear damage, so when we say allergies cause tinnitus, we mean that allergies can be associated with tinnitus.

Here, I explore how allergies and tinnitus are connected, including how allergic rhinitis, sinus congestion, or other allergy symptoms may making your tinnitus worse. I also cover how atypical migraine may explain the apparent allergy-tinnitus connection, where ear fullness and “sinus headaches” can actually be a migraine in disguise. Most practitioners are not aware of the migraine-allergy connection and how it can potentially impact tinnitus severity.

Can allergies cause tinnitus?

Technically speaking, allergies don’t cause your ears to ring; rather, they can cause pre-existing ear ringing to seem louder. Allergies can help amplify the perception of tinnitus through mechanical means via Eustachian tube issues. Alternatively, when apparent allergy symptoms (congestion, ear fullness and sinus headaches) are associated with tinnitus, it may actually be the manifestation of a migraine process.

What causes tinnitus?

The direct cause of tinnitus is damage to hair cells in the inner ear, such as from loud sounds. When sound waves hit your ear drum, the vibrations translate though the middle ear to the cochlea. Here, cochlear cells with hair like structures translate the vibration energy of sound into a neural signal via connections with auditory nerve cells.

What happens to the hearing nerve after inner ear damage?

When hair cells become damaged or die, the neurons that connect remain alive. So ironically, instead of hearing silence when these hair cells die, you hear tinnitus at the frequency corresponding to the dead hair cell because the hearing neuron is still intact. Tinnitus is essentially a phantom sound (just like a phantom limb in an amputee).

When you get clogged ears from an allergic reaction or when the migraine process is active in your brain, allergies and tinnitus become associated. In these cases, it’s not truly “allergy-induced tinnitus”; rather, its “allergy associated tinnitus”.

Can allergy symptoms cause ear buzzing tinnitus?

Allergies and ear buzzing can be related through either Eustachian tube dysfunction or the migraine process in the brain. When buzzing tinnitus fluctuates with allergy severity and the eardrums are working properly, there’s a good chance that the migraine process is responsible.

Buzzing tinnitus and ringing tinnitus are both forms of the same process. The difference is that buzzing tinnitus is usually associated with low frequency hearing loss, whereas ringing tinnitus is associated with high frequency hearing loss. 

Can Eustachian tube dysfunction cause tinnitus?

Allergic rhinitis and tinnitus may be associated through Eustachian tube dysfunction (ETD), which itself can cause tinnitus sounds to seem louder. In this sense, allergies cause tinnitus indirectly. Importantly, if this is the cause of tinnitus, it should reverse once the Eustachian tube is cleared up. If this is not the case, a migraine-related process may be responsible for the tinnitus.

What is the Eustachian tube?

The Eustachian tubes are small tubes that connect the space behind the eardrum (middle ear) with the back of the nasal passages. Their primary function is to equalize pressure in the middle ear and drain fluids from behind the eardrum. The tubes are normally closed but open once every few minutes when you swallow or yawn and equalize the pressure behind the eardrum.

What causes Eustachian tube dysfunction?

When your allergy symptoms are active (from hay fever, food allergies, or seasonal allergies), inflammation and congestion in the nasal passages can extend to the tubes, causing them to become blocked. So when you yawn or swallow, the tubes don’t open and the pressure behind the eardrum and the outside air pressure are different.

How does Eustachian tube dysfunction cause hearing loss?

The pressure issues from dysfunctional Eustachian tubes causes the eardrum (tympanic membrane) to get pulled inward and get stretched. When the eardrum gets stretched, it doesn’t vibrate as well and it causes a temporary hearing loss (called conductive hearing loss). This is when hearing is impaired because of problems with the ear canal (external ear), ear drum, or bone bones of hearing (middle ear).

How can decreased hearing make things sound louder?

Try it yourself! Put your fingers in your ears and say something. You’ll notice that your voice sounds louder when your ears are plugged. This is because when the ears are plugged, your internal sounds become louder. When dysfunctional Eustachian tubes cause reduced hearing from poor conduction, it worsens tinnitus because the tinnitus sounds in the brain sounds seem louder.  

Does congestion cause tinnitus?

Nasal congestion from any cause can worsen tinnitus, whether from allergy symptoms, chronic sinus infections, excess mucus, or runny nose from a virus (e.g., a cold or COVID). The mucus buildup from nasal congestion can block the Eustachian tube. As described above, this leads to a slight hearing loss, which in turn amplifies internal sounds like tinnitus. 

When severe, nasal congestion can also cause fluid to build up in the middle ear, making the conductive hearing loss even worse. Chronic mucus buildup can lead to ear infections. That’s why with sinus infections and ear infections, tinnitus can seem worse. It can also sometimes lead to pulsatile tinnitus, when you hear the pulsing of your heart in your ears.

What are the symptoms of middle ear and Eustachian tube problems?

Clogged ears and allergy symptoms can present in various ways, including:

• Ear Fullness: A sensation of fullness or pressure in the ears.
• Hearing Changes: Fluctuations in hearing, muffled sounds, or difficulty hearing.
• Ear Popping or Crackling: Clicking or popping sounds in the ears.
• Discomfort or Pain: Mild to moderate ear pain or discomfort.
• Dizziness: Some individuals may experience a sense of imbalance or dizziness.
• Difficulty Equalizing Pressure: Challenges equalizing ear pressure, especially in abnormal pressure changes, such as when flying.

However, the feeling of “clogged ears” may not be Eustachian tube dysfunction. Instead, it may represent a condition called “aural fullness”.

What is aural fullness?

Aural fullness refers to a sensation of fullness or pressure in the ears, often described as feeling like the ears are blocked or clogged. This may feel exactly like an allergy response, but the eardrum may be working perfectly. Medications that relieve allergy symptoms may fail to work on aural fullness.

Conditions associated with aural fullness are Meniere’s disease, idiopathic sudden sensorineural hearing loss, temporomandibular disorders, tinnitus, and migraine. Around 30% of people with tinnitus experience aural fullness, and in 70% of these, the eardrums work fine.

Tympanogram Testing For Eustachian Tube Problems

While basic treatment for Eustachian tube problems can be started at home, it’s best to consult with a healthcare professional if symptoms are prolonged. An ear nose and throat (ENT) doctor or audiologist can order a test called a tympanogram which can quickly and accurately diagnose how well the eustachian tube is working. Also, with true Eustachian tube dysfunction, the appearance of the eardrum on exam can look retracted, or sucked in.

A normal tympanogram and ear exam with a sensation of clogged ears may represent aural fullness rather than ear pressure problems. This means that a migraine-like process may be what’s going on.

Migraine, Allergies, and Ear Ringing

Allergy symptoms have also been linked to migraine, a condition where there is hypersensitivity and inflammation in the brain. Here, it’s important to understand the interconnected relationship between migraine, allergies, and tinnitus. 

Migraine and Tinnitus

There are many kinds of migraine that do not involve headaches. Recent research suggests that tinnitus may be related to a migraine-like process in the brain. In fact, migraine is being reclassified as a sensory processing disorder that’s triggered by neurogenic inflammation. The sensory hypersensitivity of migraine causes increased attention to the tinnitus sound in the brain.

Migraine and Allergies

Numerous clinical studies have documented that migraines and allergic rhinitis frequently appear together in the same person. Further, both conditions share common elements, such as inflammation and histamine reactivity. Migraine attacks also seem to increase during allergy season. Finally, people with allergies often mistake associated migraine symptoms as being “sinus headaches” (see below).

Migraine and Aural Fullness

My research team pioneered the work that outlines the connection between migraine and aural fullness [1]. The eardrum is innervated by the trigeminal nerve, the same nerve that is activated in migraine. Many patients in our clinical study on the aural fullness-migraine connection were ones who had been unsuccessfully treated for allergic rhinitis and Eustachian tube dysfunction. When we treated them with a modified migraine protocol, there were statistically significant improvements in aural fullness [2].

Migraine and Sinus Headache

“Sinus headache” is the most common misdiagnosis of migraine. We now know that the vast majority of “sinus headaches” without acute nasal inflammation are actually due to migraines [3]. It’s estimated that over 80% of migraine patients had a prior diagnosis of a sinus headache and around 95% of these had unnecessary antibiotic treatment. An additional portion had unnecessary sinus surgery before being diagnosed with migraine. People with allergies and tinnitus need to be aware of this, as typical allergy symptoms can sometimes be migraine in disguise.

The Migraine-Allergy-Tinnitus Connection

It’s possible, therefore, that allergies and tinnitus are related through a shared migraine response in the brain. Here, you can’t say “allergies cause tinnitus”; rather, the symptoms of allergies and tinnitus are both manifestations of the same migraine-like reaction in the brain.

If you still have persistent tinnitus after your allergies are under control, the tinnitus may be migraine related. In these cases, tinnitus caused by migraine will likely not respond to allergy medications (such as nasal corticosteroids or antihistamines). This is because the problem is not in the inner or middle ear; the underlying cause is the migraine process in the brain.

Treatments for Allergies and Tinnitus

The best treatment options managing allergies and tinnitus is to first be sure of the cause; is it Eustachian tube dysfunction or is it the migraine process? Effective ways to treat allergy-associated tinnitus include:

Allergy Management: If you’ve determined that allergies are causing the tinnitus, you should start to identify and avoid allergens whenever possible and use allergy medication or immunotherapy to relieve congestion. The best allergy medicine for tinnitus is probably nasal corticosteroids like Flonase. If this fails to relieve your allergic rhinitis, consulting with an allergist to evaluate your immune system may be appropriate, especially if you have asthma, sinus infections, or recurrent ear infections. You should also start to suspect a migraine-like process as the culprit for the tinnitus, rather than allergies.

Eustachian Tube Treatment: First, determine if you have Eustachian tube dysfunction rather than “aural fullness”. This may require a physical exam with an ENT or a tympanogram test. If Eustachian tube problems are confirmed, you can try techniques nasal decongestants, nasal corticosteroids, or eustachian tube exercises. Home remedies like chewing gum or yawning may help the tubes to open. In severe cases, an ENT specialist may recommend the placement of ear tubes or a procedure to use a balloon to dilate the tube through the back of the nasal passages. However, if your eardrums are working fine according to your ENT, it may represent aural fullness and migraine.

Migraine Management: If your tinnitus symptoms do not respond to typical allergy treatment, you should suspect a migraine-like process is to blame. You can adopt migraine management strategies, including certain medications, adequate sleep, hydration, and dietary changes. This strategy is most appropriate for those who have normal functioning eustachian tubes, an indication that the migraine process is behind the tinnitus and allergies. Remember, aural fullness can look exactly like Eustachian tube dysfunction. It will not respond to allergy treatment, but it will respond to migraine treatment.

Integrative Medicine Interventions: Work with a healthcare provider skilled in integrative medicine to address underlying health imbalances contributing to allergy-induced tinnitus, such as inflammation, hormonal imbalances, or nutritional deficiencies.

Conclusion: Allergies and Tinnitus May Be Migraine Related

A comprehensive approach to managing allergies and tinnitus can provide significant relief from ear ringing and enhance overall quality of life. For tinnitus symptoms that come with Eustachian tube problems, treatment options include over-the-counter medications to relieve congestion or the runny nose of allergic rhinitis. This should help any Eustachian tube issues and reduce tinnitus.

In cases that don’t respond to allergy medications, you must ask, ‘Is this allergy-related tinnitus? or is it the aural fullness and sinus headache of migraine?’. If the underlying cause is a migraine process is involved, adopting treatment options that include migraine interventions may be needed.

Allergies and Tinnitus References

[1] Risbud A, Muhonen EG, Tsutsumi K, Martin EC, Abouzari M, Djalilian HR. Migraine Features in Patients With Isolated Aural Fullness and Proposal for a New Diagnosis. Otol Neurotol. 2021 Dec 1;42(10):1580-1584.

[2] Moshtaghi O, Ghavami Y, Mahboubi H, Sahyouni R, Haidar Y, Ziai K, Lin HW, Djalilian HR. Migraine-Related Aural Fullness: A Potential Clinical Entity. Otolaryngol Head Neck Surg. 2018 Jan;158(1):100-102.

[3] Straburzyński M, Gryglas-Dworak A, Nowaczewska M, Brożek-Mądry E, Martelletti P. Etiology of ‘Sinus Headache’-Moving the Focus from Rhinology to Neurology. A Systematic Review. Brain Sci. 2021 Jan 9;11(1):79.