What causes tinnitus to worsen in the afternoon and night?

Why Tinnitus Worsens in the Afternoon and Night

Tinnitus often worsens in the afternoon and night primarily due to decreased environmental noise that would otherwise mask the tinnitus perception, leading to increased awareness of the phantom sound when surroundings become quieter.

Factors Contributing to Worsening Tinnitus in Later Hours

Environmental Noise Reduction

• During daytime hours, ambient noise from daily activities helps mask tinnitus
• As evening approaches, environmental sounds decrease, making tinnitus more noticeable
• The absence of distracting sounds at night creates conditions where tinnitus becomes more prominent

Fatigue and Stress Factors

• Mental and physical fatigue that accumulates throughout the day can exacerbate tinnitus perception
• Stress levels, which often increase during the day, can worsen tinnitus symptoms by evening
• The American Academy of Otolaryngology-Head and Neck Surgery notes that patients with tinnitus and coexisting anxiety or depression may experience more severe symptoms 1

Attention and Cognitive Factors

• Reduced cognitive distractions in the evening allow more attention to focus on tinnitus
• Lying down to sleep provides fewer sensory inputs, making the tinnitus sound more noticeable
• According to clinical guidelines, tinnitus can significantly impact quality of life and cause difficulty falling asleep 1

Physiological Changes

• Changes in blood pressure and circulation throughout the day may influence tinnitus perception
• For those with pulsatile tinnitus, changes in vascular flow or blood pressure that occur during rest may make the pulsations more noticeable 1
• Medication effects wearing off later in the day may contribute to increased tinnitus perception

Management Strategies for Evening Tinnitus

Sound Therapy

• Sound therapy options such as white noise machines, environmental sound generators, smartphone apps, and tabletop sound machines are recommended for persistent, bothersome tinnitus 2
• Using background noise during evening hours and while sleeping can help mask tinnitus perception
• Maintaining a consistent low-level sound environment can reduce the contrast between silence and tinnitus

Cognitive Behavioral Therapy (CBT)

• CBT is strongly recommended as the first-line treatment for persistent, bothersome tinnitus 2
• Techniques from CBT can help manage the heightened awareness of tinnitus in the evening
• Learning to redirect attention away from tinnitus can be particularly helpful at night

Hearing Aids

• For patients with hearing loss-associated tinnitus, hearing aids are recommended even if the hearing loss is mild 2
• Hearing aids can improve tinnitus by amplifying external sounds and reducing auditory deprivation 2
• Some hearing aids include tinnitus masking features specifically designed for nighttime use

Lifestyle Modifications

• Establishing a relaxing bedtime routine to reduce stress before sleep
• Avoiding caffeine, alcohol, and nicotine in the evening hours
• Managing evening stress through relaxation techniques such as meditation or deep breathing

Important Considerations

When to Seek Medical Attention

• Unilateral tinnitus, pulsatile tinnitus, or tinnitus associated with focal neurological abnormalities requires prompt medical evaluation 1, 2
• Tinnitus that suddenly worsens specifically in the evening may indicate an underlying condition requiring assessment
• Patients with severe anxiety or depression alongside tinnitus require prompt identification and intervention, as suicide has been reported in patients with tinnitus who have coexisting psychiatric illness 1, 2

Diagnostic Approach

• A comprehensive audiologic evaluation is recommended for patients with tinnitus to help distinguish between different types and guide appropriate treatment 2
• Imaging studies are not recommended for subjective, non-pulsatile tinnitus that doesn't localize to one ear and isn't associated with focal neurological abnormalities or asymmetric hearing loss 1
• For pulsatile tinnitus, contrast-enhanced CT angiography of the head and neck is the preferred initial study 2

By understanding why tinnitus worsens in the afternoon and night, patients can implement targeted strategies to manage their symptoms during these challenging periods, improving their quality of life and sleep.