What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) has the strongest evidence base among all interventions for tinnitus and should be the first-line treatment for patients with bothersome tinnitus. 1

Initial Evaluation and Diagnosis

• Targeted assessment should focus on:

  • Distinguishing between unilateral vs. bilateral tinnitus
  • Pulsatile vs. non-pulsatile tinnitus
  • Recent onset vs. persistent (≥6 months)
  • Bothersome vs. non-bothersome symptoms 1

• Comprehensive audiologic examination is recommended for:

  • Unilateral tinnitus
  • Tinnitus persistent for ≥6 months
  • Tinnitus accompanied by hearing problems 1, 2

• Neuroimaging is indicated only for:

  • Asymmetric or unilateral tinnitus
  • Pulsatile tinnitus
  • Tinnitus with focal neurological abnormalities
  • Tinnitus with asymmetric hearing loss 1, 2

Evidence-Based Treatment Options

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Helps develop coping strategies
   • Reduces tinnitus-related distress
   • Improves quality of life
   • Has the strongest evidence base among all interventions 1

2. Education and Counseling

   • Provide information about tinnitus mechanisms
   • Discuss realistic expectations about treatment outcomes
   • Address associated psychological factors 1

3. Hearing Aid Evaluation (for patients with hearing loss)

   • Beneficial even for mild or unilateral hearing loss
   • Improves auditory input
   • Reduces contrast between tinnitus and background sound 1

Sound-Based Therapies

1. Sound Therapy - Three primary objectives:

   • Soothing sound - Produces relief from tinnitus-associated stress
   • Background sound - Passively diverts attention by reducing contrast between tinnitus and environment
   • Interesting sound - Actively diverts attention away from tinnitus 3

2. Types of therapeutic sound:

   • Environmental sound
   • Music
   • Speech 3

3. Tinnitus Retraining Therapy (TRT)

   • Combines directive counseling with sound therapy
   • Evidence is less robust than for CBT 2, 4

Treatments to Avoid

• Medications specifically for tinnitus should not be routinely prescribed:

  • Antidepressants, anticonvulsants, anxiolytics, and intratympanic medications
  • May worsen tinnitus in some cases
  • Carry significant side effect risks 1

• Unproven supplements that may be costly and ineffective 1

Special Considerations

• Addressing psychological aspects is crucial, particularly when symptoms are bothersome 1

• Treatment of comorbidities:

  • Melatonin for sleep disturbance
  • Antidepressants for mood disorders (not specifically for tinnitus)
  • Cognitive training for cognitive impairments 2

• Prevention:

  • Avoidance of noise exposure may help prevent development or progression of tinnitus 2

Treatment Algorithm

1. For all patients with bothersome tinnitus:

   • Begin with education and counseling
   • Refer for CBT if available

2. For patients with hearing loss:

   • Hearing aid evaluation and fitting

3. For patients without hearing loss or with residual tinnitus despite hearing aids:

   • Sound therapy (background sound, music, or environmental sounds)

4. For patients with severe distress or comorbidities:

   • Address specific comorbidities (sleep, anxiety, depression)
   • Consider combination therapy (CBT + sound therapy)

The evidence consistently shows that a combination of sound therapy and CBT-based counseling provides the best outcomes for tinnitus management 5, though treatment should address the specific symptoms and impact on quality of life experienced by each patient.