What medications can help with sleep disturbances due to tinnitus?

Medications for Sleep Disturbances Due to Tinnitus

For sleep disturbances caused by tinnitus, cognitive behavioral therapy (CBT) should be considered first-line treatment, with short-term use of certain pharmacological agents as adjunctive therapy when necessary. 1, 2

First-Line Approach: Non-Pharmacological

• CBT has demonstrated significant improvement in sleep for adults with tinnitus, with a statistically significant reduction in Insomnia Severity Index scores (mean reduction of 3.28 points) 2
• Sound therapy may be recommended as a complementary approach for persistent, bothersome tinnitus 1
• Sleep hygiene education should be implemented, including regular morning/afternoon exercise, daytime exposure to bright light, maintaining a dark and quiet sleep environment, and avoiding heavy meals, alcohol, and nicotine near bedtime 1

Pharmacological Options for Short-Term Use

When medication is needed for short-term management of sleep disturbances:

Recommended Medications:

• BZD receptor agonists:

  • Eszopiclone (2-3 mg): Effective for both sleep onset and maintenance insomnia 1
  • Zaleplon (10 mg): Helpful specifically for sleep onset insomnia 1
  • Zolpidem (5-10 mg): Effective for both sleep onset and maintenance insomnia; recommended initial dose is 5 mg for women and 5-10 mg for men, taken once nightly immediately before bedtime 1, 3

• Benzodiazepines (short-term use only):

  • Temazepam (15 mg): May help with both sleep onset and maintenance insomnia 1
  • Triazolam (0.25 mg): Useful for sleep onset insomnia 1

• Other options:

  • Ramelteon (8 mg): A melatonin receptor agonist effective for sleep onset insomnia 1
  • Low-dose Doxepin (3-6 mg): Effective for sleep maintenance insomnia 1

Not Recommended:

• Melatonin supplements are not recommended for tinnitus-related sleep disturbances despite some positive preliminary research 1, 3, 4
• Antidepressants (except low-dose doxepin), anticonvulsants, and anxiolytics should not be routinely used for treating tinnitus-related sleep problems 1
• Dietary supplements including Ginkgo biloba, zinc, or L-tryptophan are not recommended 1
• Trazodone, tiagabine, and diphenhydramine are not recommended for insomnia treatment 1

Special Considerations

• Hyperarousal appears to be a common mechanism in both tinnitus and insomnia, which may explain their frequent co-occurrence 5
• For elderly or debilitated patients, use lower doses (e.g., 5 mg of zolpidem) due to increased sensitivity to medication effects 3
• Patients with hepatic impairment require dose adjustments; avoid zolpidem in severe hepatic impairment 3
• Be cautious with medication combinations, especially with other CNS depressants 3

Treatment Algorithm

1. Begin with CBT and sound therapy as first-line approaches 1, 2
2. Implement proper sleep hygiene measures 1
3. If sleep disturbance persists:
   • For sleep onset issues: Consider zaleplon, zolpidem, or ramelteon 1
   • For sleep maintenance issues: Consider eszopiclone, zolpidem, or low-dose doxepin 1
4. Limit pharmacological treatment to short-term use (generally less than 4 weeks) 1
5. Monitor for side effects and dependency with benzodiazepines and non-benzodiazepine hypnotics 1

Common Pitfalls to Avoid

• Using medications as the sole treatment without addressing the underlying tinnitus distress 1
• Long-term use of benzodiazepines or Z-drugs, which can lead to dependence 1
• Overlooking the bidirectional relationship between tinnitus and sleep disturbance (poor sleep worsens tinnitus perception, which further impairs sleep) 5, 6
• Using over-the-counter sleep aids like diphenhydramine, which have poor efficacy and potentially significant side effects, especially in older adults 1