Ross Hauser, MD

Hyperacusis is a reduced tolerance for everyday sound. A conversation, dishes clattering, a vacuum cleaner, traffic, or even a person’s own voice may feel excessively loud, threatening, or physically painful. Some people begin wearing earplugs much of the day or withdrawing from work, restaurants, family gatherings, and other ordinary activities.

At Caring Medical, the patients who ask us about hyperacusis rarely have sound sensitivity as their only problem. More typically is the person who reaches out to us with a medical history filled with diagnosis surrounding hearing issues. For instance a history may go like this:

I am currently diagnosed with Eustachian Tube Dysfunction, ear pain and fullness on the right side. I have ringing in both ears, occasional hyperacusis both ears, dizziness, nasal passage closures depending on how I turn my head. (Please see my article Neck Pain Chronic Sinusitis and Eustachian Tube Dysfunction). Lying flat alleviates symptoms. Lying with my head on a pillow causes me to shake. I also get eye pain along with back, neck and shoulder pain.

And another history:

I suffer from excruciating loud tinnitus, it started a few years back. My tinnitus is so loud that masking sounds need to be so loud they would cause hearing damage. I also have hyperacusis, I cannot endure a loud room or noises. Ear fullness, painful eustachian tubes. Headaches every day, some are migraine level. Light sensitivity. (Please see my article Cranial Neuralgias – Symptoms of pain, smell, vision, hearing, taste and talking.) Brain fog, disorientation, depersonalization. Please see my article (Dissociation, Anxiety, Personality Disorders and Depression – Uncontrolled emotion in cervical spine instability patients.)

Had two prior cervical fusions. X-rays show a lack of proper curvature from the fusions, very straight neck.

What is hyperacusis?

Hyperacusis is not simply “good hearing.” It is an abnormal reaction to sounds that most people tolerate comfortably. Researchers describe several overlapping experiences:

• Loudness hyperacusis: ordinary sounds seem disproportionately loud.
• Pain hyperacusis: sound produces stabbing, burning, pressure, or ear pain.
• Fear hyperacusis: certain sounds provoke fear because the person expects them to cause harm or worsen symptoms.
• Annoyance hyperacusis: particular sounds provoke an unusually intense emotional response.

These categories may overlap. Hyperacusis can also coexist with tinnitus, hearing loss, migraine, post-traumatic symptoms, anxiety, or other sound-tolerance disorders. Current models emphasize altered processing within both auditory and non-auditory brain networks rather than a single ear abnormality in every patient. (1)

Hyperacusis, misophonia, phonophobia, and autophony are different

These terms are sometimes used interchangeably, but they describe different experiences.

• Misophonia is a strong emotional or autonomic reaction to specific patterned sounds, such as chewing or tapping, even when the sound is not loud.
• Phonophobia is fear of sound and is also used to describe sound sensitivity during migraine.
• Autophony means hearing one’s own voice, breathing, eye movements, or other internal sounds unusually loudly. It may occur with conditions such as superior semicircular canal dehiscence or a patulous Eustachian tube.
• Tinnitus is the perception of sound without a matching external source.

Because these problems require different investigations, a precise symptom history matters.

Why sounds may become intolerable

The ear converts sound waves into electrical signals that travel along the auditory nerve to the brain. The brain then filters, interprets, and assigns meaning to those signals. One influential explanation for hyperacusis is increased central auditory gain. In plain language, the central nervous system may turn up its internal “volume control,” amplifying sound-related activity after changes in auditory input or neural processing. Hyperacusis can also recruit networks involved in pain, attention, emotion, memory, and threat detection. (1)

This helps explain why two patients with similar hearing tests can experience sound very differently. It also explains why hyperacusis may occur with tinnitus, migraine, head trauma, fibromyalgia, autism spectrum disorder, Williams syndrome, and other neurologic or systemic conditions.

Common and important causes

Before attributing sound sensitivity to the neck, patients should receive an appropriate ear and hearing evaluation. Depending on the history, possible contributors include:

• recent acoustic trauma or chronic noise exposure;
• hearing loss or other cochlear injury;
• migraine or vestibular migraine;
• concussion or traumatic brain injury;
• facial nerve dysfunction, including Bell’s palsy;
• middle-ear muscle disorders;
• Ménière’s disease or other inner-ear disorders;
• superior semicircular canal dehiscence;
• Eustachian tube dysfunction;
• medication effects;
• temporomandibular joint dysfunction;
• neurologic, infectious, autoimmune, or genetic disorders; and
• anxiety, post-traumatic stress, or other conditions that can amplify threat responses without making symptoms imaginary.

An otolaryngologist and audiologist may use otoscopy, pure-tone audiometry, speech testing, tympanometry, acoustic reflex testing, and carefully performed loudness-discomfort measurements. Additional vestibular testing or imaging may be appropriate when symptoms suggest a structural ear or neurologic disorder.

Symptoms requiring prompt medical evaluation: Urgent evaluation is warranted for sudden hearing loss, new one-sided neurologic weakness, facial paralysis, severe acute vertigo, drainage or blood from the ear after trauma, a sudden severe headache, or pulsatile tinnitus that follows the heartbeat. Rapidly progressive one-sided hearing symptoms also deserve timely specialist assessment.

Can the cervical spine influence auditory symptoms?

There is a biologically plausible connection between the neck and some auditory symptoms, but the evidence is much stronger for somatosensory tinnitus than for hyperacusis specifically.

Sensory information from the cervical spine and jaw converges with auditory pathways in the brainstem. In some patients, tinnitus changes when they rotate the neck, clench the jaw, press on muscles, or alter posture. This does not prove cervical instability, but it shows that musculoskeletal input can modulate auditory processing in selected people.

Neck trauma may also affect multiple systems at once. Whiplash or concussion can be followed by neck pain, headache, dizziness, migraine, tinnitus, and sound sensitivity. In such cases, the ear, brain, vestibular system, jaw, and cervical spine may all require assessment rather than forcing every symptom into one diagnosis.

Our clinical perspective on cervical instability and hyperacusis

At Caring Medical, we become more interested in a possible cervical contribution when a patient has several of the following features:

• sound sensitivity began after whiplash, concussion, repetitive neck strain, or another cervical injury;
• symptoms reliably change with head position, prolonged flexion, or neck movement;
• significant neck pain, headaches, dizziness, imbalance, or facial symptoms accompany the hyperacusis;
• symptoms coexist with tinnitus and neck pain;
• there is a history of hypermobility or Ehlers-Danlos syndrome;
• examination suggests upper cervical dysfunction or excessive motion; or
• standard ear-focused evaluation has not fully explained the symptom pattern.

Ligaments restrain excessive movement between cervical vertebrae. When these supporting tissues are injured or lax, abnormal motion may produce pain, muscle guarding, altered proprioception, and irritation of nearby neural structures. Our earlier narrative review described capsular ligament laxity as one possible contributor to chronic neck pain and associated symptoms, including tinnitus and dizziness. As a narrative review, it proposed a clinical framework; it did not establish that cervical instability causes hyperacusis or that Prolotherapy treats it. (2)

Our 2024 Frontiers in Neurology article further proposed that cervical dysstructure and upper cervical instability may affect vascular and neural structures in the neck. That publication included a retrospective clinic cohort and mechanistic discussion. It did not specifically test hyperacusis treatment, so its relevance here is hypothesis-generating rather than proof. (3)

The middle-ear muscles: an interesting but unproven cervical mechanism

Two small muscles help regulate movement of the middle-ear bones: the tensor tympani, supplied by a branch of the trigeminal nerve, and the stapedius, supplied by the facial nerve. Dysfunction within this protective system has been discussed in sound-tolerance disorders.

We have proposed that abnormal cervical mechanics, muscle guarding, or altered neural input could influence the wider sensory-motor network involved in sound regulation. This may be relevant when sound sensitivity occurs with jaw, facial, head, and neck symptoms. However, there is not yet direct clinical-trial evidence showing that atlantoaxial instability disables these muscles or that correcting cervical instability normalizes them. This proposed pathway should therefore be presented as a clinical hypothesis, not an established cause.

How we evaluate a possible cervical contribution

Our evaluation begins with the chronology and pattern of symptoms. We ask what started first, whether there was trauma, which positions aggravate symptoms, and whether sound sensitivity changes with neck motion or posture. We also review prior ENT, audiology, neurology, vestibular, dental, and imaging findings.

The physical examination may include posture, cervical range of motion, upper cervical tenderness, neurologic screening, joint-position sense, and signs of generalized hypermobility. When medically appropriate, we may use digital motion X-ray or other imaging to assess motion that static images may not show. Imaging findings must still be interpreted alongside the history and examination; an imaging abnormality alone does not prove the source of hyperacusis.

Patients with prominent dizziness or imbalance may also require vestibular assessment. Those with suspected vascular or neurologic symptoms need appropriate specialist evaluation before an elective musculoskeletal treatment plan is considered.

Treating associated conditions

Migraine management, hearing rehabilitation, treatment of an identified ear disorder, TMJ care, sleep support, and treatment for anxiety or post-traumatic stress may all be appropriate. When neck or jaw movement clearly modulates tinnitus or sound intolerance, carefully selected physical therapy may be reasonable. Aggressive neck manipulation is not appropriate for every patient, particularly when instability, vascular disease, inflammatory disease, or connective-tissue disorders are suspected.

Prolotherapy

Prolotherapy is an injection treatment intended to stimulate a reparative response in injured ligaments and tendons. At Caring Medical, we may consider it when a complete evaluation identifies symptomatic cervical ligament injury or instability that reasonably fits the patient’s broader clinical pattern.

We do not present Prolotherapy as a standard or proven direct treatment for hyperacusis. There are currently no high-quality randomized trials demonstrating that cervical Prolotherapy treats hyperacusis. If treatment is proposed, the target is the diagnosed cervical ligament problem—not the auditory symptom in isolation. Expected benefits, uncertainties, alternatives, costs, and procedure-specific risks should be discussed before a patient decides.

Patients whose symptoms are exclusively auditory, whose evaluation indicates a primary ear disorder, or whose history and examination do not support cervical involvement are unlikely to be appropriate candidates for a neck-focused treatment.

Summary

Hyperacusis is a real and potentially disabling disorder of sound tolerance. The best-supported explanation involves altered auditory gain and interaction between auditory, pain, attention, emotional, and threat-processing networks. Ear disease, hearing loss, migraine, acoustic trauma, neurologic conditions, and other recognized causes must be considered.

The cervical spine may be one contributing source of abnormal sensory input in a subgroup of patients—especially after neck trauma or when symptoms change consistently with posture or movement. What has not been established is that cervical instability is a common cause of hyperacusis or that treating cervical ligaments reliably resolves it.

At Caring Medical, our goal is to identify whether a patient’s sound sensitivity belongs to a larger, coherent pattern of cervical dysfunction while respecting the limits of the current evidence. The most useful plan often combines appropriate ENT and audiology care with evaluation of migraine, vestibular, jaw, neurologic, and cervical factors rather than assuming that one explanation fits everyone.

Continue reading

Tinnitus, cervical spine instability, and neck pain

Meniere’s Disease and hearing problems caused by cervical neck instability

References

1 Salvi R, Chen GD, Manohar S. Hyperacusis: Loudness intolerance, fear, annoyance and pain. Hearing Research. 2022;426:108648. [Google Scholar]
2 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The Open Orthopaedics Journal. 2014;8:326-345. [Google Scholar]
3 Hauser RA, Matias D, Rawlings B. The ligamentous cervical instability etiology of human disease from the forward head-facedown lifestyle: emphasis on obstruction of fluid flow into and out of the brain. Frontiers in Neurology. 2024;15:1430390. [Google Scholar]
4 Henry JA. Sound therapy to reduce auditory gain for hyperacusis and tinnitus. American Journal of Audiology. 2022;31(4):1191-1202. [Google Scholar]

Medical disclaimer: This article is for educational purposes and is not a diagnosis or a substitute for individualized medical care. Sudden hearing loss, acute neurologic symptoms, severe vertigo, head or neck trauma with new symptoms, or pulsatile tinnitus requires prompt medical evaluation. Treatments discussed may or may not be appropriate or effective for an individual patient.

peracusis and Tinnitus. American Journal of Audiology. 2022 Nov 15:1-1. [Google Scholar]