First-Line Treatment for Tinnitus
For patients with persistent, bothersome tinnitus, the first-line treatments are education/counseling, hearing aid evaluation (if hearing loss is present), and cognitive behavioral therapy (CBT). 1, 2, 3
Assessment and Classification
- Distinguish between bothersome and non-bothersome tinnitus, and determine if tinnitus is recent onset or persistent (≥6 months) to guide treatment decisions 1, 2
- A comprehensive audiologic examination is recommended, especially for unilateral, persistent tinnitus, or tinnitus associated with hearing difficulties 2, 3
- Classify tinnitus as pulsatile or non-pulsatile, as pulsatile tinnitus may require imaging evaluation 4
First-Line Treatment Algorithm
1. Education and Counseling
- All patients with persistent, bothersome tinnitus should receive education about management strategies 1, 2, 3
- Counseling about the natural course of tinnitus and coping strategies is essential for improving quality of life 3
2. Hearing Aid Evaluation
- For patients with hearing loss and tinnitus, a hearing aid evaluation is strongly recommended, even if the hearing loss is only mild or unilateral 1, 2
- Hearing aids can help manage both hearing loss and tinnitus symptoms simultaneously 3
- This is considered a first-line audiologic intervention with high confidence in the evidence 1, 2
3. Cognitive Behavioral Therapy (CBT)
- CBT should be recommended for all patients with persistent, bothersome tinnitus 1, 2, 3
- This recommendation is based on randomized controlled trials showing a preponderance of benefit over harm 2, 5
- CBT is the only treatment that has been shown to definitively improve quality of life in patients with tinnitus in large randomized controlled trials 5
4. Sound Therapy
- Sound therapy may be recommended as an additional treatment option 1, 6
- This can include environmental sound, music, or speech to provide relief, reduce contrast between tinnitus and the acoustic environment, or divert attention 6
Treatments Not Recommended
- Medications including antidepressants, anticonvulsants, anxiolytics, or intratympanic medications should not be routinely recommended for treating persistent, bothersome tinnitus 1, 2, 3
- Dietary supplements such as Ginkgo biloba, melatonin, zinc, or other supplements are not recommended 1, 2
- There is insufficient evidence to make a recommendation for or against acupuncture 1, 2
Special Considerations
- Patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention due to increased suicide risk 4, 7
- For patients with recent onset tinnitus (< 6 months), watchful waiting may be appropriate as symptoms may resolve spontaneously 1
- The combination of sound therapy and CBT-based counseling has the strongest evidence base 8
Common Pitfalls to Avoid
- Failing to identify underlying treatable causes of tinnitus before initiating symptomatic treatment 7
- Recommending unproven medical therapies or supplements that may have side effects without proven benefit 1, 2
- Neglecting to address hearing loss, which is frequently associated with tinnitus 2, 8
- Delaying CBT, which has the strongest evidence for improving quality of life 2, 5