What are the treatment options for tinnitus?

Treatment Options for Tinnitus

The most effective evidence-based treatment for persistent, bothersome tinnitus is a combination of sound therapy and cognitive behavioral therapy (CBT), with CBT being the only intervention proven to improve quality of life in tinnitus patients. 1

Initial Assessment and Diagnosis

Before initiating treatment, proper evaluation is essential:

• Audiologic examination: Should be obtained promptly for all patients with persistent tinnitus 1
• Imaging studies: Only indicated for patients with:
  • Unilateral tinnitus
  • Pulsatile tinnitus
  • Focal neurological abnormalities
  • Asymmetric hearing loss 1, 2

Treatment Algorithm

First-Line Interventions

1. Education and Counseling

   • Explain tinnitus mechanisms
   • Reassure that tinnitus is manageable and rarely indicates serious disease
   • Discuss relationship between anxiety, stress, and symptom worsening 1

2. Sound Therapy

   • Hearing aids: Recommended when hearing loss is identified (even mild or unilateral) 1
   • Sound generators: Options include white noise machines, tabletop sound generators, ear-level masking devices 1
   • Environmental sound enrichment: Background sounds to reduce tinnitus perception 1

3. Cognitive Behavioral Therapy (CBT)

   • Most effective evidence-based intervention for tinnitus 1
   • Helps develop coping strategies
   • Changes negative thought patterns about symptoms
   • Should be tinnitus-specific when available 1, 3

What to Avoid

• Medications: Do not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for tinnitus as they lack evidence of benefit 1
• Supplements: Ginkgo biloba, melatonin, zinc, and other dietary supplements are not recommended due to lack of efficacy 1
• Transcranial magnetic stimulation: Not recommended for routine treatment 1

Special Considerations

Pulsatile Tinnitus

Requires different evaluation approach with possible vascular imaging (CT angiography) to rule out vascular abnormalities 2

Tinnitus with Hyperacusis

Sound therapy should be carefully introduced as it can help desensitize the auditory system over time 1

Psychological Comorbidities

• Monitor for signs of depression or severe anxiety
• Patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention due to increased suicide risk 2, 1

Follow-Up Management

• Schedule follow-up within 4-6 weeks to assess response to initial management
• If symptoms persist or worsen, consider referral to a specialized tinnitus clinic 1
• Primary tinnitus is typically idiopathic with no cure, but symptoms can be mitigated with appropriate therapies 2

Efficacy of Treatments

The evidence base is strongest for a combination of sound therapy and CBT-based counseling 3. While many treatments are available, most lack robust evidence of effectiveness. CBT is the only treatment that has consistently shown improvement in quality of life measures in randomized controlled trials 4, 1.

Common Pitfalls to Avoid

• Overuse of imaging: Neuroimaging is not part of standard workup unless specific indicators are present 4
• Medication focus: Seeking pharmaceutical solutions when evidence supports behavioral and sound-based approaches
• Ignoring psychological aspects: Failing to address anxiety and depression that frequently accompany tinnitus
• Promising a cure: Tinnitus is often a chronic condition that requires management rather than expecting complete resolution