What are the treatment options for tinnitus?

Tinnitus Treatment Options

Cognitive Behavioral Therapy (CBT) combined with sound therapy is the most effective first-line treatment for tinnitus management. 1

First-Line Treatment Options

Cognitive Behavioral Therapy

• CBT is recommended as the primary treatment by the American College of Audiology due to its strong evidence base 1
• Acceptance and Commitment Therapy (ACT) is particularly effective among CBT variations, focusing on accepting tinnitus while pursuing valued life activities 1
• CBT is the only treatment that has been shown to improve quality of life in patients with tinnitus 2

Education and Counseling

• Patient education about tinnitus mechanisms and management strategies is essential 1
• Should include information about:
  • The natural progression of tinnitus
  • Avoidance of noise exposure to prevent progression
  • Stress reduction techniques

Second-Line Treatment Options

Hearing Aids

• Recommended for patients with hearing loss (even if mild or unilateral) 1, 3
• Should be considered even with minimal hearing loss as they can provide significant relief

Sound Therapy

• Used as a complement to other treatments to reduce tinnitus perception 1
• Can be implemented through three approaches:
  1. Soothing sound: Produces relief from tinnitus-associated stress 4
  2. Background sound: Passively diverts attention by reducing contrast between tinnitus and environment 4
  3. Interesting sound: Actively diverts attention away from tinnitus 4
• Sound types include environmental sounds, music, and speech 4

Combined Approach

• The combination of sound therapy and CBT-based counseling shows the strongest evidence for tinnitus management 1, 3
• This combined approach addresses both the auditory and psychological aspects of tinnitus

Patient Evaluation and Monitoring

When to Refer to an Audiologist

• Patients with severe tinnitus (interferes with daily life) 1
• Tinnitus that persists beyond medication discontinuation
• Unilateral tinnitus
• Tinnitus associated with hearing difficulties

When to Consider Imaging

Imaging is indicated only in specific cases:

• Unilateral tinnitus: CT scan or MRI with internal auditory canal protocol
• Pulsatile tinnitus: Temporal bone CT scan or CT angiography
• Focal neurological abnormalities: CT scan or MRI
• Asymmetric hearing loss: CT scan or MRI 1

Red Flags Requiring Immediate Attention

• Worsening headache
• Focal neurological deficits
• Confusion or memory problems
• Increased sleepiness 1

Treatments to Avoid

Medications and Supplements

• Dietary supplements (Ginkgo biloba, melatonin, zinc) are not recommended 1
• Antidepressants, anticonvulsants, and anxiolytics should be avoided except in acute phase 1
• No effective drug treatments are currently available 3

Other Interventions

• Transcranial Magnetic Stimulation (TMS) is not recommended due to insufficient evidence 1
• Acupuncture is not recommended due to insufficient evidence 1

Special Considerations

Medication-Induced Tinnitus

• Discontinue the causative medication if tinnitus occurs 1
• Medication-induced tinnitus typically resolves upon discontinuation of the offending agent

Tinnitus with Sleep Disturbance

• Melatonin may help with sleep disturbance, though not directly treating tinnitus 2
• Sound therapy can be particularly helpful during sleep hours

Treatment Algorithm

1. Start with CBT and education/counseling
2. Add sound therapy concurrently with CBT
3. Provide hearing aids if any degree of hearing loss is present
4. Monitor progress and adjust approach based on response
5. Consider specialist referral if symptoms persist despite treatment

The evidence is strongest for a combination approach that addresses both the auditory and psychological aspects of tinnitus, with CBT forming the cornerstone of effective management.