Is amitriptyline (tricyclic antidepressant) associated with tinnitus or buzzing sounds?

Amitriptyline and Tinnitus: Association and Management

Yes, amitriptyline is associated with tinnitus as a known adverse effect, listed in the FDA drug label under CNS and neuromuscular side effects. 1

Evidence for Amitriptyline-Tinnitus Association

• The FDA drug label for amitriptyline explicitly lists tinnitus as a potential adverse reaction in the CNS and neuromuscular category 1
• Case reports document tinnitus occurring even with low-dose amitriptyline treatment 2
• Tinnitus can manifest as various sounds including ringing, buzzing, clicking, or roaring noises as perceived by the patient 3

Paradoxical Effect: Treatment vs. Causation

Interestingly, amitriptyline presents a paradoxical relationship with tinnitus:

• While it can cause tinnitus as a side effect, amitriptyline has also been studied as a treatment for subjective tinnitus 4, 5
• A network meta-analysis found that amitriptyline was associated with the highest improvement in tinnitus severity among pharmacologic treatments for primary tinnitus 6
• However, a Cochrane review concluded there is insufficient evidence to definitively support antidepressants for tinnitus treatment 7

Risk Factors and Mechanisms

• Tricyclic antidepressants like amitriptyline can affect neurotransmitter systems involved in auditory processing 5
• The anticholinergic properties of amitriptyline may contribute to tinnitus development 1
• Higher doses and prolonged administration appear to increase the risk of developing tinnitus 2

Clinical Implications and Management

• For patients experiencing tinnitus while on amitriptyline:

  • Consider dose reduction if clinically appropriate 2
  • Evaluate for other potential causes of tinnitus (hearing loss, Menière's disease, etc.) 3
  • Assess the impact on quality of life, as tinnitus can significantly affect psychological well-being 3

• For patients with severe tinnitus:

  • Consider alternative medications if amitriptyline is suspected as the cause 1
  • Cognitive behavioral therapy (CBT) may help manage tinnitus-related distress 3
  • Hearing aids or other assistive devices may benefit patients with concomitant hearing loss 3

Important Considerations

• Tinnitus affects 10-15% of adults in the general population, so causality with amitriptyline must be carefully evaluated 3
• Patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention due to increased suicide risk 3
• When prescribing amitriptyline, inform patients about the potential risk of tinnitus as part of informed consent 1
• If tinnitus develops, document its characteristics (unilateral/bilateral, constant/intermittent, quality of sound) to help determine causality 3

Monitoring Recommendations

• Baseline assessment of auditory symptoms before starting amitriptyline 3
• Regular follow-up to assess for emergence of tinnitus or other auditory symptoms 3
• If tinnitus develops, consider audiological evaluation to assess for other contributing factors 3