What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the most effective treatment for tinnitus, with the strongest evidence base among all interventions for reducing tinnitus-related distress and improving quality of life. 1

Initial Evaluation and Diagnosis

• Targeted assessment should focus on:

  • 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 necessary for:

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

• Neuroimaging (MRI/CT) is indicated only for:

  • Asymmetric or unilateral tinnitus
  • Pulsatile tinnitus (requires CT angiography or MRI/MRA)
  • Tinnitus with focal neurological abnormalities
  • Tinnitus with asymmetric hearing loss 1, 2

First-Line Treatment Options

1. Cognitive Behavioral Therapy (CBT)

   • Helps patients develop coping strategies
   • Reduces tinnitus-related distress
   • Improves quality of life
   • Has the strongest evidence base among all interventions 1, 3, 2

2. Hearing Aid Evaluation

   • Recommended for patients with hearing loss (even mild or unilateral)
   • Improves auditory input
   • Reduces contrast between tinnitus and background sound
   • Enhances quality of life 1

3. Sound Therapy

   • Provides relief from tinnitus-associated stress
   • Offers passive distraction from tinnitus
   • Can be delivered through:
     • Environmental sound
     • Music
     • Speech
   • Used to achieve three objectives:
     • Producing relief from tinnitus-associated stress (soothing sound)
     • Passively diverting attention (background sound)
     • Actively diverting attention (interesting sound) 1, 4

4. Education and Counseling

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

Treatment Approaches Based on Tinnitus Duration

Acute Tinnitus

• Pharmacological approaches are common but lack strong evidence 5
• Early intervention with sound therapy may be beneficial
• Address any underlying treatable causes

Chronic Tinnitus (≥6 months)

• Focus on audiological and psychological approaches 5
• CBT is particularly indicated
• Sound therapy and tinnitus retraining therapy are options
• Hearing aids when hearing loss is present 1, 3

Important Cautions and Pitfalls

• Avoid routine prescription of medications specifically for tinnitus:

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

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

• Avoid recommending unproven supplements that may be costly and ineffective 1

• Do not neglect addressing hearing loss, which often accompanies tinnitus and can exacerbate symptoms 1

• Do not overlook psychological aspects of tinnitus management, particularly when symptoms are bothersome 1

Special Considerations

• Pulsatile tinnitus requires a different evaluation approach with vascular imaging to rule out vascular abnormalities 1

• Unilateral tinnitus warrants more thorough investigation to rule out vestibular schwannoma or other dangerous causes 2

• Tinnitus with sleep disturbance may benefit from melatonin 2

• Tinnitus with mood disorders may benefit from antidepressants (though not prescribed specifically for the tinnitus itself) 2

Despite the variety of treatment options available, it's important to note that there is no single universally effective treatment for tinnitus, and success rates remain suboptimal 5. The combination of sound therapy and CBT-based counseling currently has the strongest evidence base 3.