Is Transcranial Magnetic Stimulation (TMS) a viable treatment option for patients with tinnitus?

Transcranial Magnetic Stimulation (TMS) for Tinnitus

Clinicians should not recommend TMS for the routine treatment of patients with persistent, bothersome tinnitus. 1

Evidence-Based Recommendation

The 2014 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guideline on tinnitus explicitly recommends against using transcranial magnetic stimulation (TMS) for treating persistent, bothersome tinnitus. This recommendation is based on inconclusive randomized controlled trials and systematic reviews showing low strength of evidence 1.

Rationale for Recommendation Against TMS

The evidence against TMS for tinnitus treatment is substantial:

• Inconclusive efficacy: Multiple RCTs and systematic reviews demonstrate low strength of evidence for TMS effectiveness 1
• Lack of long-term benefit: High confidence in the absence of long-term (>6 months) benefits 1
• Inconsistent short-term results: Only a minority of trials showed transient beneficial outcomes, and the strength of this evidence is low 1
• Potential harms: Financial costs and physical risks without established benefits 1

Unresolved Issues with TMS for Tinnitus

Recent research (2023) highlights numerous unresolved issues with TMS for tinnitus treatment 2:

• Variability in TMS systems and configurations
• Differences in coil type, orientation, and placement
• Inconsistency in stimulation parameters (frequency, intensity, sessions)
• Heterogeneity in study populations and outcome measures

Recommended Tinnitus Management Approaches

Instead of TMS, the clinical practice guideline recommends several evidence-based approaches:

1. Hearing aid evaluation for patients with hearing loss and persistent, bothersome tinnitus 1
2. Cognitive-behavioral therapy (CBT) - strongly recommended based on RCTs with preponderance of benefit over harm 1
3. Sound therapy may be recommended for persistent, bothersome tinnitus 1

Treatments to Avoid

The guideline also recommends against several other treatments:

• Medical therapy: Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications 1
• Dietary supplements: Ginkgo biloba, melatonin, zinc, or other supplements 1

Special Considerations

While some recent research shows potential for TMS in specific scenarios:

• A 2024 study suggests sequential multilocus rTMS might benefit some patients, particularly those without comorbid major depressive disorder 3
• Combined approaches (TMS followed by CBT) have shown promise in case reports 4

However, these findings are preliminary and do not override the guideline recommendation against routine use of TMS for tinnitus.

Imaging Considerations

The American College of Radiology notes that imaging is not indicated in all cases of tinnitus and is usually not appropriate for symmetric or bilateral, subjective, nonpulsatile tinnitus in the absence of other symptoms 1.

Conclusion

Despite ongoing research interest in TMS for tinnitus, current clinical practice guidelines clearly recommend against its routine use. The evidence supporting TMS remains inconclusive, with significant methodological limitations in existing studies. Clinicians should instead focus on established treatments like CBT, hearing aids (when hearing loss is present), and sound therapy for managing persistent, bothersome tinnitus.