What are the treatment options for tinnitus?

Treatment Options for Tinnitus

For patients with persistent, bothersome tinnitus, cognitive-behavioral therapy (CBT) and hearing aid evaluation (for those with hearing loss) are the most strongly recommended first-line interventions, while medications, dietary supplements, and transcranial magnetic stimulation should not be routinely used. 1

Initial Assessment and Categorization

When evaluating a patient with tinnitus, it's essential to:

1. Distinguish between types of tinnitus:

   • Subjective (heard only by patient) vs. objective (audible to examiner)
   • Pulsatile vs. non-pulsatile
   • Unilateral vs. bilateral
   • Recent onset (<6 months) vs. persistent (≥6 months)
   • Bothersome vs. non-bothersome

2. Rule out serious underlying causes:

   • Neuroimaging is indicated for patients with unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 1
   • Comprehensive audiologic evaluation is recommended for unilateral tinnitus, persistent tinnitus (≥6 months), or tinnitus associated with hearing difficulties 1, 2

Evidence-Based Treatment Algorithm

First-Line Interventions:

1. Education and Counseling 1

   • Provide information about tinnitus mechanisms, natural history, and management strategies
   • Discuss realistic expectations about treatment outcomes

2. Hearing Aid Evaluation (for patients with hearing loss) 1

   • Recommended even for mild hearing loss or unilateral sensorineural hearing loss
   • Benefits tinnitus by improving auditory input and reducing contrast between tinnitus and background sound

3. Cognitive-Behavioral Therapy (CBT) 1

   • Strongest evidence base among all interventions
   • Helps patients develop coping strategies and reduce tinnitus-related distress
   • Improves quality of life even when tinnitus loudness remains unchanged

4. Sound Therapy 1, 3, 4

   • May be recommended as part of management
   • Options include:
     • Environmental sound enrichment
     • Sound generators/maskers
     • Combination devices (hearing aid plus sound generator)
     • Music therapy
   • Can be used for:
     • Relief from tinnitus-associated stress (soothing sounds)
     • Passive distraction (background sounds)
     • Active distraction (interesting sounds)

Interventions NOT Recommended:

1. Medications 1

   • Antidepressants, anticonvulsants, anxiolytics, and intratympanic medications should not be routinely prescribed specifically for tinnitus
   • May worsen tinnitus in some cases and carry significant side effect risks
   • Note: May be appropriate for treating comorbid conditions (depression, anxiety, insomnia)

2. Dietary Supplements 1

   • Ginkgo biloba, melatonin, zinc, and other supplements lack sufficient evidence
   • Should not be recommended for tinnitus management

3. Transcranial Magnetic Stimulation (TMS) 1

   • Not recommended for routine treatment

4. Acupuncture 1

   • Insufficient evidence to make a recommendation

Special Considerations

• Pulsatile Tinnitus:

  • Requires different evaluation approach
  • Imaging (CT angiography or MRI/MRA) is indicated to rule out vascular abnormalities 1

• Acute vs. Chronic Tinnitus:

  • Treatment approaches differ based on duration
  • Pharmacological approaches more common in acute tinnitus 5
  • Audiological and psychological approaches more appropriate for chronic tinnitus 5

• Comorbid Conditions:

  • Anxiety and depression frequently co-occur with tinnitus
  • Prompt identification and intervention for severe anxiety/depression is critical
  • Patients with tinnitus and psychiatric illness require careful monitoring due to suicide risk 1

Common Pitfalls to Avoid

1. Overuse of imaging in patients with non-pulsatile, bilateral tinnitus without focal neurologic findings or asymmetric hearing loss 1

2. Prescribing medications specifically for tinnitus without evidence of benefit 1

3. Recommending unproven supplements that may be costly and ineffective 1

4. Failing to address hearing loss which often accompanies tinnitus and can exacerbate symptoms 1

5. Neglecting psychological aspects of tinnitus management, particularly when symptoms are bothersome 1, 2

6. Setting unrealistic expectations for complete tinnitus resolution rather than focusing on management and quality of life improvement 2