What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the strongest evidence-based treatment for improving quality of life in patients with persistent, bothersome tinnitus and should be recommended as first-line therapy. 1, 2

Classification and Initial Evaluation

• Tinnitus should be classified as pulsatile or non-pulsatile, and primary or secondary, to guide appropriate treatment 1
• Pulsatile tinnitus (especially unilateral) almost always requires imaging evaluation, as it frequently indicates underlying vascular abnormalities that may be treatable 1, 3
• A comprehensive otologic examination is essential to identify potential vascular retrotympanic masses 1
• Audiologic evaluation is necessary for patients with unilateral tinnitus, tinnitus persisting ≥6 months, or tinnitus associated with hearing difficulties 2, 4

Evidence-Based Treatment Algorithm

First-Line Treatments

• Cognitive Behavioral Therapy (CBT): Recommended for all patients with persistent, bothersome tinnitus based on strong evidence showing benefit over harm 2, 5
• Hearing aids: Recommended for patients with hearing loss and tinnitus, even if the hearing loss is mild or unilateral 1, 2
• Education and counseling: Essential components for all patients with persistent tinnitus 1, 2

Treatments Not Recommended

• Medical therapy including antidepressants, anticonvulsants, anxiolíticos, or intratympanic medications are not recommended for treating persistent, bothersome tinnitus 2
• Dietary supplements such as Ginkgo biloba, melatonin, zinc, or other supplements should not be recommended 3, 2
• Transcranial Magnetic Stimulation (TMS) is not recommended for routine tinnitus treatment 2

Special Considerations

For Pulsatile Tinnitus

• First-line imaging should include CT of temporal bone and/or CT angiography of head and neck with contrast 3
• Second-line imaging should include MRI and MR angiography with contrast 3
• Specific treatments depend on underlying cause:
  • Arterial dissection: anticoagulation or antiplatelet therapy 3
  • Sigmoid sinus diverticulum or dehiscence: surgical repair or endovascular embolization 3
  • Superior semicircular canal dehiscence: surgical repair for severe symptomatic cases 3

For Non-Pulsatile Tinnitus

• Sound therapy may be considered as part of the management strategy, although evidence is less conclusive 4, 5
• Addressing any underlying hearing loss is crucial, as it is frequently associated with tinnitus 2
• For patients with severe anxiety or depression related to tinnitus, prompt psychiatric evaluation is recommended due to increased suicide risk 1

Common Pitfalls to Avoid

• Failing to distinguish between bothersome and non-bothersome tinnitus, which affects treatment decisions 2
• Neglecting to perform imaging studies for unilateral or pulsatile tinnitus, which may miss serious underlying pathology 1, 3, 6
• Using medications (antidepressants, anticonvulsants) as primary treatment for tinnitus without addressing underlying causes 3, 2
• Overlooking mild hearing loss that could benefit from hearing aids 1, 2
• Relying on unproven supplements or treatments without sufficient evidence 3, 2