What is the best treatment for tinnitus?

Best Treatment for Tinnitus

Cognitive-behavioral therapy (CBT) and hearing aid evaluation are the first-line treatments for persistent, bothersome tinnitus, with CBT having the strongest evidence base among all interventions. 1

Diagnostic Evaluation Before Treatment

Before initiating treatment, proper evaluation is essential:

1. Targeted history and physical examination to identify potentially treatable underlying causes 2

   • Distinguish between unilateral vs. bilateral tinnitus
   • Pulsatile vs. non-pulsatile tinnitus
   • Recent onset vs. persistent (≥6 months)
   • Bothersome vs. non-bothersome symptoms

2. Audiologic evaluation 2

   • Recommended for unilateral tinnitus, persistent tinnitus (≥6 months), or tinnitus associated with hearing difficulties
   • Should be performed promptly, preferably within 4 weeks of assessment

3. Neuroimaging 2, 1

   • Only indicated for:
     • Unilateral tinnitus
     • Pulsatile tinnitus
     • Focal neurological abnormalities
     • Asymmetric hearing loss

Treatment Algorithm for Persistent, Bothersome Tinnitus

First-Line Treatments:

1. Cognitive-Behavioral Therapy (CBT) 2, 1, 3

   • Strongest evidence base among all interventions
   • Helps patients develop coping strategies
   • Reduces tinnitus-related distress
   • Improves quality of life even when tinnitus loudness remains unchanged
   • Only treatment shown to definitely improve tinnitus in large randomized controlled trials

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

   • Recommended even for mild hearing loss or unilateral sensorineural hearing loss
   • Benefits tinnitus by:
     • Improving auditory input
     • Reducing contrast between tinnitus and background sound
     • Enhancing quality of life

3. Education and Counseling 2, 1

   • Provide information about tinnitus mechanisms and management strategies
   • Discuss realistic expectations about treatment outcomes
   • Address associated psychological factors

Second-Line Treatment:

1. Sound Therapy 2, 1, 4
   • May be recommended as part of management
   • Options include:
     • Environmental sound enrichment
     • Sound generators/maskers
     • Combination devices
     • Music therapy
   • Provides relief from tinnitus-associated stress or passive distraction
   • Evidence is less robust than for CBT

Treatments to Avoid

1. Medications 2, 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

2. Dietary Supplements 2, 1

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

3. Transcranial Magnetic Stimulation (TMS) 2

   • Not recommended for routine treatment

Special Considerations

• Pulsatile tinnitus requires a different evaluation approach, with imaging (CT angiography or MRI/MRA) indicated to rule out vascular abnormalities 1

• Comorbid conditions such as anxiety and depression frequently co-occur with tinnitus and require prompt identification and intervention 1, 5

• Recent onset tinnitus (< 6 months) may resolve spontaneously, so aggressive intervention may be deferred initially 2, 6

Common Pitfalls to Avoid

• Overuse of imaging in patients with non-pulsatile, bilateral tinnitus without focal neurologic findings or asymmetric hearing loss 2, 1

• Prescribing medications specifically for tinnitus without evidence of benefit 2, 1

• Recommending unproven supplements that may be costly and ineffective 2, 1

• Failing to address hearing loss, which often accompanies tinnitus and can exacerbate symptoms 2, 1

• Neglecting psychological aspects of tinnitus management, particularly when symptoms are bothersome 2, 1, 7